How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636) Radiofrequency ablation (RFA), also called radiofrequency neurotomy is an interventional pain management procedure that involves heating a part of a pain-transmitting nerve with a radiofrequency needle to create a heat lesion. Some of our pain physicians offices are asking the question - How to Document radiofrequency ablation (RFA) of nerves CPT (64635, +64636. What is the proper way of reporting this kind of procedure on the medical record when performed?  Here's a guidance from CPT Assistant Article published on May 2020, quotes: Question: When performing radiofrequency ablation (RFA) of nerves (64635, 64636), is it necessary that the operative report documents the specific facet joints at which the RFA with imaging occurred as well as the nerves treated or denervated? Answer: Yes, RFA procedures should clearly state which nerves were ablated and which joints were treated. Codes 64635, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint, and 64636, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure), are reported for each joint treated, not each nerve treated. Stating the specific nerve and the level it innervates eliminates confusion and ensures accurate reporting. Reference: CPT Assistant Published on May 2020 
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The World Health Organization or the WHO made a code for ICD-10 (not ICD-10-CM) which is the U07.2, COVID-19, virus not identified, intended to give the ability to capture suspected uncertain patients. The reason you are getting errors in billing this code is that because U07.2 Covid-19, virus not identified has not been imported into ICD-10-CM (not yet) and its coming up as invalid. It is actually a valid code. So the guidance is to code the signs and/or symptoms and/or (for example) reporting ICD-10-CM Code Z20.828 - this code is a very code that we can report. Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. I always suggest that if you have cases where you only see one code such as the U07.2 Covid-19, virus not identified , we need to go back the our providers and let them if they can give you a more appropriate codes based on signs and symptoms and as documented on their medical record.  |
 Pinky Maniri-Pescasio
Founder and CEO of GoHealthcare Practice Solutions
Pinky Maniri-Pescasio, MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in A.I. Governance is a nationally recognized leader in Revenue Cycle Management, Utilization Management, and Healthcare AI Governance with over 28 years of experience navigating Medicare, CMS regulations, and payer strategies. As the founder of GoHealthcare Practice Solutions, LLC, she partners with pain management practices, ASCs, and specialty groups across the U.S. to optimize reimbursement, strengthen compliance, and lead transformative revenue cycle operations. Known for her 98% approval rate in prior authorizations and deep command of clinical documentation standards, Pinky is also a Certified Specialist in Healthcare AI Governance and a trusted voice on CMS innovation models, value-based care, and policy trends. She regularly speaks at national conferences, including PAINWeek and OMA, and works closely with physicians, CFOs, and administrators to future-proof their practices. Current HFMA Professional Expertise Credentials: HFMA Certified Specialist in Physician Practice Management (CSPPM) HFMA Certified Specialist in Revenue Cycle Management (CRCR) HFMA Certified Specialist Payment & Reimbursement (CSPR) HFMA Certified Specialist in Business Intelligence (CSBI) 
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