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Key documentation elements include: Two documented positive MBBs (dates, percentage of relief, duration) Numeric pain scale recorded before and after each diagnostic block Confirmed failure of conservative treatment (physical therapy, medications) MRI or CT confirming facet degeneration or spondylosis (for some MACs) Procedure note including electrode placement, temperature, and impedance readings High Audit Risk: RFA is a primary focus of CMS Recovery Audit Contractor (RAC) and Zone Program Integrity Contractor (ZPIC) reviews
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