Unilateral vs bilateral RFA

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so55b

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I just researched about wRVU for unilateral vs bilateral lumbar radiofrequency ablation and I got this answer from Deepseek. So it seems the wRVU is the same for uni and bilateral? Did you guys know about this? It is the same for medial branch blocks according to Deepseek.


Calculation for Unilateral RFA (L4-5 and L5-S1)
First level (L4-5): CPT 64635 = 3.00 wRVU

Second level (L5-S1): CPT 64636 = 2.00 wRVU

Total wRVU: 5.00

Calculation for Bilateral RFA (L4-5 and L5-S1)
First level (L4-5 bilateral): CPT 64635-50 = 3.00 wRVU

Second level (L5-S1 bilateral): CPT 64636-50 = 2.00 wRVU

Total wRVU: 5.00


Key Rules
Coding is per facet joint level, not per nerve or side.
Example: L4-5 (one level) involves ablating two medial branch nerves (L3 and L4), but it’s coded as one unit of 64635.

Bilateral vs. Unilateral:
wRVUs are identical for unilateral and bilateral procedures.
Payment differs: Bilateral procedures (modifier 50) reimburse at 150% of the unilateral rate.
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Isn't it 1.5 x the rvu? So 4.5 + 3 = 7.5 rvu for bilateral

We always do unilateral RFA and bring them back in 3 weeks for other side.
 
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Off the bat, the round numbers should have told you your AI was FOS.

I get 3.78 for 64635, 5.67 for 64635B and 1.16 for 64636 and 1.74 for 64636B

therefore 4.94 for unilateral 2 level RF and 7.41 for Bilateral 2 level RF

The circle jerk of bringing a patient in for multiple procedures is not worth my time. I have plenty of patients, so the extra 6 minutes is easy to do the contralateral side, collect 2.47 RVU compared to unilateral and move on.

I have never been able to understand how this was worthwhile for those prolonging this process to get "full charges" instead of the discounted contralateral side, unless you don't have anything better to do and don't value your patient's time.
 
Not sure, its just how this place has always done it. In fellowship we did b/l RFA (except cervical)
 
cowboydoc said:
Off the bat, the round numbers should have told you your AI was FOS.

I get 3.78 for 64635, 5.67 for 64635B and 1.16 for 64636 and 1.74 for 64636B

therefore 4.94 for unilateral 2 level RF and 7.41 for Bilateral 2 level RF

The circle jerk of bringing a patient in for multiple procedures is not worth my time. I have plenty of patients, so the extra 6 minutes is easy to do the contralateral side, collect 2.47 RVU compared to unilateral and move on.

I have never been able to understand how this was worthwhile for those prolonging this process to get "full charges" instead of the discounted contralateral side, unless you don't have anything better to do and don't value your patient's time.
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Below is what Deepseek answered when I asked for clarification. Can you challenge this? I don’t know much about coding, so I just wanted a clearer explanation. I would appreciate it if you could clarify the answer.
(I did not do with web search so it may miss recent data after 2024)

Here’s the exact 2023 wRVU data for lumbar RFA (CPT 64635/64636) and evidence that bilateral procedures do not increase wRVUs:

Exact 2023 wRVU Values​


64635Paravertebral facet joint nerve destruction, first level (e.g., L4-5)3.00
64636Each additional level (e.g., L5-S1)2.00

[th]
CPT Code

[/th][th]
Description

[/th][th]
2023 Work RVU

[/th]

Source: 2023 Medicare Physician Fee Schedule (MPFS)

  • Step-by-Step Verification:
    1. Go to the CMS PFS Look-Up Tool.
    2. Select 2023, search CPT 64635 or 64636, and check the "Work RVU" column.

Evidence: Bilateral Procedures Do NOT Increase wRVUs​

CMS explicitly states that wRVUs are tied to the CPT code itself, not modifiers (e.g., modifier 50 for bilateral procedures).

1. CMS Medicare Claims Processing Manual (Chapter 12, Section 20.6.1)​

  • Payment Adjustment: Bilateral procedures are paid at 150% of the unilateral rate.
  • RVU Impact: RVUs (including work, practice expense, and malpractice) do not change with modifiers like 50.
Click to expand...
Direct Quote:
"Bilateral surgeries are paid at 150% of the fee schedule amount for unilateral surgeries. The RVUs are not multiplied by 150%."
Source: CMS Manual, Chapter 12, Section 20.6.1
Click to expand...

2. 2023 MPFS Final Rule​

  • Page 69727: "Modifier 50 (bilateral procedure) does not affect the RVUs assigned to a service. The payment adjustment for bilateral procedures is applied to the fee schedule amount."
    Source: 2023 MPFS Final Rule (Federal Register)
Click to expand...

​

​

Example: Bilateral L4-5 and L5-S1 RFA​


64635503.00150% of unilateral
64636502.00150% of unilateral
Total—5.00 wRVU—

[th]
CPT Code

[/th][th]
Modifier

[/th][th]
wRVU

[/th][th]
Payment Adjustment

[/th]


Key Takeaway:
  • wRVU Total: 3.00 (64635) + 2.00 (64636) = 5.00 wRVU (same as unilateral).
  • Payment: 150% of the fee schedule amount for bilateral, but wRVUs remain unchanged.

How to Confirm​

  1. CMS PFS Look-Up Tool:
    • Enter CPT codes 64635/64636 with modifier 50. The "Work RVU" column will still show 3.00 and 2.00.
    • Link: CMS PFS Search
 
Last edited:
RFA for bilateral is definitely less. Staged unilateral 2 level lumbar RFA is 4.48 each time so 8.96 total. Doing bilateral 2 level lumbar RFA is 6.72. So total of 2.24 less RVU for the same amount of work.
 
I do 2 units of the second code for bilateral, not 50 mod. So it’s closer

mdo1738 said:
RFA for bilateral is definitely less. Staged unilateral 2 level lumbar RFA is 4.48 each time so 8.96 total. Doing bilateral 2 level lumbar RFA is 6.72. So total of 2.24 less RVU for the same amount of work.
Click to expand...

.
 
paindoc007 said:
I do 2 units of the second code for bilateral, not 50 mod. So it’s closer



.
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Please explain. I have noticed that our billers will do something similar - I think one level is billed with a -50 modifier and the other level is billed twice without the modifier. I thought they were screwing something up, but based on your post, they may actually know what they are doing.
 
mdo1738 said:
RFA for bilateral is definitely less. Staged unilateral 2 level lumbar RFA is 4.48 each time so 8.96 total. Doing bilateral 2 level lumbar RFA is 6.72. So total of 2.24 less RVU for the same amount of work.
Click to expand...
For my time, I’m actually more efficient in the add-on time for the bilateral (second side) than the unilateral only. (16 RVU/hr vs 14 roughly). For scheduling purposes (30 min for unilateral and 45 for bilateral), my RVU/hr is almost exactly the same. What’s more, patients have one procedure, one recovery, and are back to life faster.
 
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deep seek is wrong.

go directly to the source.

1738240319379.png


RVU25A | CMS

www.cms.gov www.cms.gov

so the numbers 3 and 2 are completely wrong.

CMS allows 50% payment for bilateral levels.

so 3.32 +3.32x50% + 1.16+1.16x50% = 4.98 + 1.74 = 6.72 for bilateral 2 level lumbar RFA.
 
Do bilateral, not unilateral ablations whenever possible. I always do bilateral lumbar, but I do not do cervical bilaterally (though I do bilateral cervical MBB).

Get it done, move onto the next patient, keep the line moving.
 
MitchLevi said:
Do bilateral, not unilateral ablations whenever possible. I always do bilateral lumbar, but I do not do cervical bilaterally (though I do bilateral cervical MBB).

Get it done, move onto the next patient, keep the line moving.
Click to expand...
i've started doing bilateral cervical - most patients dont have any difference in pain/neuritis with bilateral vs unilateral
 
What do you tell the patients when you schedule unilateral lumbar ablations? "I am doing this so I can make more money, there is no clinical reason you need to wait, miss more work, find an additional driver and take on the extra risk, but I gotta get those 2 wRVUs." I just don't get it.
 
kstarm said:
What do you tell the patients when you schedule unilateral lumbar ablations? "I am doing this so I can make more money, there is no clinical reason you need to wait, miss more work, find an additional driver and take on the extra risk, but I gotta get those 2 wRVUs." I just don't get it.
Click to expand...

Those “2 RVUs” makes a difference of $50k+ per year for me. My patients have not found it burdensome. Part of it may be patient population, as many of my patients don’t have a lot else going on. And for those who have reasons to do bilateral, I am perfectly fine with it. But my RFA volume is such that I’m definitely not eating $50-60k a year.
 
I wouldn't have a problem having patients come in for a different visit for each side, but with the new Medicare guidelines that they will only cover 2 RFA sessions per year per body region then it makes it a difficult situation. As much as I try to be technically good, my RFAs don't always last a full year.
 
@mdo1738 different situation for private practice vs HOPD. Most saying bilateral are private practice. In private practice, the $50 cost for needles, kit, grounding pad make a difference. Also, we have to be mindful of the rolling 12 month limit. In the HOPD, that’s on them and they are willing to take the risk of paying you out for a case that doesnt pay to get the $2000 facility fee x 2. So both the private docs and the HOPD docs are correct for their own situations.
 
mdo1738 said:
Those “2 RVUs” makes a difference of $50k+ per year for me. My patients have not found it burdensome. Part of it may be patient population, as many of my patients don’t have a lot else going on. And for those who have reasons to do bilateral, I am perfectly fine with it. But my RFA volume is such that I’m definitely not eating $50-60k a year.
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its not 50-60K. please be honest
 
mdo1738 said:
Those “2 RVUs” makes a difference of $50k+ per year for me. My patients have not found it burdensome. Part of it may be patient population, as many of my patients don’t have a lot else going on. And for those who have reasons to do bilateral, I am perfectly fine with it. But my RFA volume is such that I’m definitely not eating $50-60k a year.
Click to expand...
so 461 RF sessions with conservative $65 rvu? I dont buy that, unless you're doing 10-20 in a day ...
 
mdo1738 said:
Those “2 RVUs” makes a difference of $50k+ per year for me. My patients have not found it burdensome. Part of it may be patient population, as many of my patients don’t have a lot else going on. And for those who have reasons to do bilateral, I am perfectly fine with it. But my RFA volume is such that I’m definitely not eating $50-60k a year.
Click to expand...
Sure, what do you tell your patients as to the reason why you do each side on a different day?
 
mdo1738 said:
8-10 RFA per week, 48 weeks per year
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even if thats the case (im dubious), you cant just subtract out those cases. if you are indeed that busy, those slots will be filled. you will actually be LOSING money by not doing a more lucrative procedure during that time slot. you already have the patient prepped and draped. they are laying right there. spend the extra 5-10 minutes and get the extra 50% then and there.
 
SSdoc33 said:
even if thats the case (im dubious), you cant just subtract out those cases. if you are indeed that busy, those slots will be filled. you will actually be LOSING money by not doing a more lucrative procedure during that time slot. you already have the patient prepped and draped. they are laying right there. spend the extra 5-10 minutes and get the extra 50% then and there.
Click to expand...

You are assuming I’m not doing both the RFA and the other hypothetical procedures.
 
paindoc007 said:
To minimize SE. To improve tolerance to the procedure. Insurance and their rules. This is how I practice, take it or leave it. Who cares. Say whatever you want. None of them will know any different.
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How does doing one side separately minimize side effects? Especially if you are using any type of sedation.
 
paindoc007 said:
To minimize SE. To improve tolerance to the procedure. Insurance and their rules. This is how I practice, take it or leave it. Who cares. Say whatever you want. None of them will know any different.
Click to expand...
well the insurance part is a LIE, insurance doesn't tell you to do one side at a time.
 
buddababa said:
well the insurance part is a LIE, insurance doesn't tell you to do one side at a time.
Click to expand...

Not a lie. He didnt say they tell you to do one side at a time. They do tell you that you’re getting a 50% pay cut for bilateral. That is their rule. Therefore due to insurance rules, will need to be done staged unilateral.

Crazy to blame the doc for not doing underpaid work when the insurance company is the culprit.
 
mdo1738 said:
Not a lie. He didnt say they tell you to do one side at a time. They do tell you that you’re getting a 50% pay cut for bilateral. That is their rule. Therefore due to insurance rules, will need to be done staged unilateral.

Crazy to blame the doc for not doing underpaid work when the insurance company is the culprit.
Click to expand...
I'm doing two bilateral ablations every time you do two unilaterals, which also means my clinic collections are higher than you because I am seeing more new patient visits and follow ups, ordering more in house PT, more XRAY's, MRIs and CTs. The line keeps moving so I am servicing more patients than you, and my doing bilateral RFAs is a large reason why. You're doing 8-10 RFA per week, and you could be doing 12-15 with a higher number of new patient clinic visits, and this leads to more epidurals, stimulators and advanced procedures as well. It's more medical management pts, which means more urine labs. Bob is right about buying needles, grounding pads, etc, but if you're HOPD that doesn't matter to you but it does make the system less efficient from a total healthcare cost perspective.

You're focusing on one small aspect of this IMO.
 
buddababa said:
i've started doing bilateral cervical - most patients dont have any difference in pain/neuritis with bilateral vs unilateral
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My reason for not doing cervical bilaterally is I have seen someone with complete drop head syndrome after an outside doctor did an RFA. I had to give the pt a rigid neck brace. It was an astonishing visual that I will never forget.
 
mdo1738 said:
You are assuming I’m not doing both the RFA and the other hypothetical procedures.
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that is debatable under Medicare guidelines. you shouldnt be and if you are, you have to justify why.

in addition, you should be careful about whether the carrier will pay the full amount or only pay 50% of the wRVU for the second side.

(ps yes, that has happened to me)
 
Anyone have the link to the cms verbiage allowing 50% rvu for second side?
 
BobBarker said:
@mdo1738 different situation for private practice vs HOPD. Most saying bilateral are private practice. In private practice, the $50 cost for needles, kit, grounding pad make a difference. Also, we have to be mindful of the rolling 12 month limit. In the HOPD, that’s on them and they are willing to take the risk of paying you out for a case that doesnt pay to get the $2000 facility fee x 2. So both the private docs and the HOPD docs are correct for their own situations.
Click to expand...
Can you elaborate more on how there is a difference between PP and HOPD. I don't see a difference and still strongly believe HOPD should be doing bilateral RFA. Someone mentioned the burden of inconvenience including driver, having to take a day off, sedating twice if applicable etc.

It works well on my patients and lasts about 6 months so getting to do bilateral RFA twice per year is huge and the 14 or so RUV per year beats the heck out of >>>>> right RFA, then left RFA for 9 RVU per year
 
As a HOPD RVU 🥷 your reason for being employed is to generate facility fees. The way to generate the most facility fees is to split the sides for RFA. The hospital will pay him his units whether it gets paid or not. They also pay for all of the supplies. There is no benefit to him to do bilateral.
 
not the most specific referral for 150%, but there is this:


1738270860802.png


there are other notifications that state 150% for bilateral procedures.

BobBarker said:
As a HOPD RVU 🥷 your reason for being employed is to generate facility fees. The way to generate the most facility fees is to split the sides for RFA. The hospital will pay him his units whether it gets paid or not. They also pay for all of the supplies. There is no benefit to him to do bilateral.
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this may be true though i do not know if the entire facility fee is generated for the second side procedure, and each side may count as one of the injections allowable per year for that segment of the body.

in addition, for patients who have copays and deductibles, this is a major cause for concern, and why i do bilateral procedures excepting cervical.
 
1st bilateral level should be billed with -50 modifier

All subsequent levels should be billed x 2 with (Rt, Lft) modifiers
 
BobBarker said:
I tried that and couldn’t get the claims to go here locally. Novitas contractor. -50 for both levels.
Click to expand...
Yeah I’ve heard that for some carriers. I’m not sure why they don’t all just follow the CMS guidelines.

We got a memo 2 yrs ago from CMS stating all multilevel bilateral procedures were going to this new coding system. Many carriers apparently haven’t caught on
 
It’s 50 modifier for the first and second level here.

Ultimately it is what it is. It’s quicker to do two level bilateral than total time for two level unilateral which is how I rationalize it being paid less for the work. I place all needles, lesion one side while the other is already numbed then lesion contralateral.

Patients can only get two RFAs per body section per year so if your RFAs are lasting less than 12 months on average, you are doing right by the patient in my opinion by doing bilateral.
 
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