Rhizotomy Procedures

The terms “rhizotomy” and “Radiofrequency Ablation” (RFA) both mean “destruction of a nerve.” Another term for this is “neurolysis.”

The CPT coding choices for a rhizotomy procedure reflect the methods chosen to destroy the nerve(s).

Nerve Destruction choices include the following:

1. Chemical Neurolytic Blocks - These require substances that are injected at the nerve to destroy them. Common substances used include the following (not an inclusive list): phenol, ethyl alcohol, hypertonic saline, and some others. This is an injection, either through a needle or a small catheter.

2. Cryoablative Techniques - A small incision is created through which a cannula/catheter/needle is inserted with a probe to freeze/destroy the nerves.

3. Radiofrequency Lesioning - This procedure cuts part or all of the nerve using electro-thermal currents. A probe is placed at or on the nerve with wires attached. These probes are about the same size as the needles used for injections and are placed in a similar way as a facet joint injection.
   
   With Radiofrequency, there are two kinds:

1. single or continuous radiofrequency current to destroy the nerve(s); the electrical current heats the tip of the needle to 80 degrees Celsius or greater, creating a lesion that destroys the nerve(s)

2. pulsed-wave, which are short bursts of radiofrequency current rather than the continuous flow of the single or continuous method.
   
   The CPT codes for the continuous RFA and chemical denervation injections will depend on the spinal levels and generally range from 64633-64636. The descriptor for all levels includes “Destruction by neurolytic agent” or “chemodenervation.” The result is the same for each technique or method used, which is destruction of the nerve. Regardless of the number of nerves destroyed, we report these codes once per spinal facet joint level. With the exception of Pulsed-wave Radiofrequency, each method is considered a neurolytic agent.
   
   Pulsed-wave radiofrequency is usually considered “experimental” by payers and is coded using an unlisted CPT code per most payers, AMA, and AAOS:
   
   “Coding Clarification CPT codes 64633, 64634, 64635, and 64636 only apply to thermal radiofrequency ablation. CPT code 64999 is to be used for pulsed radiofrequency ablation.”
   
   http://www.aaos.org/govern/federal/issues/UHCAblativeTreatmentforSpinalPain.pdf 
   
   The 2018 CPT book also has a narrative note above CPT 64633; if the temperature is less than 80 degrees Celsius or if it’s pulsed radiofrequency, we are to report this procedure using an unlisted code, 64999.

4. Neurosurgical Procedures - these are presumed to be somewhat open procedures and/or aren’t necessarily considered “minimally invasive” or injection procedures like those discussed above. The objective is to destroy the nerve for reasons that may include other than chronic pain, such as hyperhidrosis.

1. laminectomy with rhizotomy - the removal of spinal bone with severing of nerve roots; radiofrequency or neurolytic used to destroy the nerve after the laminectomy is done. This is done via injection, radiofrequency, or other chemical means after the laminectomy is performed. The key word here is “laminectomy” or removal of spinal bone in order to reach the affected nerves.
   
   The CPT code for this procedure is 63185 or 63190, depending on how many spinal bone segments (lamina) are removed.

2. sympathectomy - removal or cutting out of the sympathetic nerve chain for various reasons and is usually performed through an open incision or via endoscope that helps the surgeon see the nerves.
   
   CPT codes for this range from 64802-64823; lumbar sympathectomy, for example, is 64818. Some payers require an unlisted code, 64999, for endoscopic sympathectomy.

3. “mechanical destruction” - This procedure uses a percutaneous catheter that is left in for several days for multiple injections of a neurolytic agent to treat the adhesions or scar tissue. It may also be performed on a single day, where adhesions are lysed or cut mechanically. The catheter or a brush is sometimes used to cut the nerves, as found in the RACZ procedure, CPTs 62263-62267. To use these codes, the procedure is performed percutaneously, through a small catheter.
   
   Per the AAOS (see link above) and AMA, there are no codes that describe when the mechanical destruction is performed during an open spinal procedure. The unlisted code, CPT 64999 must be used.
   
   When performed during an open spinal procedure, if the surgeon doesn’t describe the “mechanical destruction” of nerve(s) in the operative notes except to say that it was via endoscope, this leads the adjusters to presume that the standard of care and work involved in this procedure is similar to the nerve destruction as described above using CPT codes 64633, 64634, 64635, and 64636 like an injection/needle via a catheter.

Leslie Johnson, CPC is an Admin for Jobs fro American Medical Coders (JFAMC) social media groups as well as Chief Web Tech for the websites: AskLeslie.net, CodingAdvisory.com, JFAMC.org, and CRNHealthcare.com

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