AHA Coding Clinic® for HCPCS - 2010 Issue 3; ASK the EDITOR

Trigeminal Balloon Compression Rhizotomy

The patient with a diagnosis of trigeminal neuralgia was scheduled to undergo a right sided trigeminal balloon compression rhizotomy with use of fluoroscopy. According to the operative report, the right side of the patient’s face was prepped for the procedure and the rhizotomy needle was advanced under fluoroscopy to the center of the foramen ovale. The balloon catheter was inserted in good position and inflated. There is no documentation of a neurolytic agent being administered. The procedure was performed and the patient was discharged in good condition. We are having some difficulty locating an appropriate CPT code for this procedure and wondered whether we could report CPT code 64610 or 64999? Please assist us with the assignment of an appropriate CPT code for the trigeminal balloon compression rhizotomy performed? ...

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