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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Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Consultant.