Watch How You Code for Facet Joint Injections

In 2006, the Centers for Medicare & Medicaid Services (CMS) allowed approximately $96 million in improper payments for facet joint injections services and an additional $33 million in improper payments for associated facility claims, according to an Office of Inspector General (OIG) September report. That’s a whopping 63 percent of facet joint injection services allowed by Medicare in 2006 that did not meet Medicare program requirements. This finding and the realization that Medicare Part B payments for facet joint injections have increased from $141 million in 2003 to $307 million in 2006a 76 percent increase in the number of Medicare claims for facet joint injectionshas prompted the OIG’s recommendation for CMS to take certain measures.

The OIG recommends CMS:

  • Assist carriers in developing ways to scrutinize claims for facet joint injections;
  • Strengthen program safeguards;
  • Clarify billing instructions for bilateral services; and
  • Take appropriate action regarding improper payments identified in the OIG’s sample.

How sure are you that your physician or facility’s policy for facet joint injections meets Medicare program requirements? To ensure compliancy, you should determine what policies and safeguards currently exist.

The National Correct Coding Initiative Policy Manual (NCCI manual) for Medicare Services and the Medicare Claims Processing Manual state that you should use modifiers to indicate when a service differs from CPT® definition. Up to two modifiers are allowed for each CPT® code on a claim. Use modifier 50 bilateral procedures to indicate bilateral facet joint injections performed on both the right and left sides of a level. This increases reimbursement to 150 percent of the base rate. If a physician performs multiple bilateral injections, attach modifier 50 to each facet joint injection code.

Primary codes 64470 Injection; Paravertebral facet joint or facet joint nerve; cervical/thoracic, single level and 64475 Injection; Paravertebral facet joint or facet joint nerve; lumbar/sacral, single level include pre-surgical and post surgical expenses related to the procedure. Use add-on codes to represent additional levels, not sides. Do not bill multiple lines of CPT® add-on codes +64472 Injection; Paravertebral facet joint or facet joint nerve; cervical/thoracic, each additional level and +64476 Injection; Paravertebral facet joint or facet joint nerve; lumbar/sacral, each additional level in addition to the primary code.

Aside from that, no national coverage determination exists, so look to your carrier’s local coverage determination (LCD) for further guidance regarding:

  • Indications and limitations of coverage and medical necessity;
  • Covered diagnosis codes;
  • Documentation requirements; and
  • Utilization guidelines.

In addition to proper coding, always submit the medical record with documentation of the services, describing the procedure. Procedure notes must include details, such as which levels and sides of the back were injected. Make sure the medical record contains a history or physical exam to show the treatment was medically indicated. Additionally, include imaging studies in the record to support the diagnosis and treatment.

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29 Responses to “Watch How You Code for Facet Joint Injections”

  1. Suzanne Winter says:

    With regard to your statement in this article, “Do not bill multiple lines of CPT add-on codes +64472 and +64476” then how can the provider bill for 3-4 different levels? We are accustom to seeing L3 as 64470-50, L4 as +64472-50, L5 as +64472-50. Are you saying the provider cannot bill different lines of the add-on codes to represent different levels? Did you want to say bill the number of add-on codes in units? I’m confused. Please clarify. Thanks Suzanne

  2. Debra Mitchell, MSPH, CPC-H says:

    I am uncertain what you mean when you state to not bill multiple lines of the add on codes, the codes clearly state each additional level and the CMS 1500 billing manual states that units may be used only for quantity distribution items such as timed codes or drugs, and never for surgical procedures so the only way to do this is by listing multiple line items using the 59 modifer for each additional level.
    Thank You
    Debra Mitchell

  3. Natalya Nikolayeva says:

    I agree with Debra Mitchell comments. But instead of modifier -59 I would use -51 for multiple levels.

    Respectfully,
    Natalya

  4. Carol Kohler says:

    I believe what the intent here is to not bill multiple INDIVIDUAL lines for each add’l level, but rather indicate the number of total units on one line. For example:

    10/1/08 64470 $xxx.xx 001 (for the initial/single level)
    10/1/08 64472 $xxx.xx 005 (for the additional levels)

    If the facets were done bilaterally, it would look like:

    10/1/08 64470-50 $xxx.xx 001
    10/2/08 64472-50 $xxx.xx 005

    With the amount charged reflecting the bilateral procedure. This is the way I read it. Please correct me if I am in error. Thank you!

  5. Mildred Smith says:

    “Use add-on codes to represent additional levels, not sides. Do not bill multiple lines of CPT® add-on codes +64472 Injection; Paravertebral facet joint or facet joint nerve; cervical/thoracic, each additional level and +64476 Injection; Paravertebral facet joint or facet joint nerve; lumbar/sacral, each additional level in addition to the primary code.”

    Would you please explain. I thought the purpose of ” each additional” would be to bill 1 line for each level?

    Thank you

  6. Sue DeLancy, CPC says:

    I agree with Mildred Smith and Debra Mitchell. We need clarification on how to bill each additional level if multiple lines are not permitted. CPT clearly states for add on codes +64472 and +64476 each additional level, list separately.

    Thank you,
    Sue DeLancy

  7. Carol Kohler says:

    I worked in the insurance industry for nearly 18 years. Whenever a CPT description said to “list separately” .. that simply meant if additional procedures were done, they were to be listed on a separate line item from the primary procedure. A lot of insurance companies (including Medicare) have multiple surgery rules in place (i.e. primary 100% of allowance, 2nd 75% of allowance, etc.)

    By splitting 64472 into multiple individual lines, multiple surgery rules may be enforced as most systems calculate 1st line, 2nd line, etc.

    According to the Nebraska Medicare Part B fee schedule, 64470 allows up to $249.30, each additional level, 64472, allows $104.27. That would be per each level – meaning if you did 5 additional levels, the maximum allowance would be $521.35 for all 5.

  8. TRACIE RUSSELL says:

    I agree with Carol on Oct 1st. This is the correct way to bill.
    On Oct 2nd however, Carol states by “splitting into multiple individual lines, multiple surgery guidlines would apply?” Add on codes are exempt from modifier 51.
    The payment for add on codes are already adjusted. So regardless of how billed payment is the same, you get paid for the primary (1st level) then for each level therafter.

  9. Kathleen Hayden, CPC, CCP-P says:

    My experience with the billing of facet blocks is two fold. First many physicians are not aware of the
    guidelines for counting of the additional level. Many think it is per injection when in fact it is per each
    level that is treated.

    Second. As far as the billing of the additional levels I have found that many carriers ask for the
    cpt code (64472, 64476) to be billed on 1 line with the number of additional levels in the units field.
    Depending on the policy you can bill up to 2 or 3 additional levels without submitting additional
    documentation. Unilateral injections should have the RT or LT attached. Bilaterals should be
    billed on 1 line with the -50 modifier attached and a 1 in the units field, unless otherrwise indicated
    within a carriers medical policy.

    As far as using the -51 modifier. All add on codes are exempt from the -51 modifier. If it is requested it is by individual carrier specific guidelines. As of yet I have not personally seen
    the -51 requested

    I have found it saves a lot of grief to get to know your state carriers medical policies on the billing
    of facet blocks or any other pain management procedure.

  10. Marian says:

    We bill units for these procedures and get paid in PA. What is the average levels done in these procedures.

  11. KAREN COLLINS, CPC says:

    I WORK FOR 3 PAIN MANAGMEMENT PRACTICES AND WE BILL ADDITONAL LEVELS OUT DAILY. I HAVE FOUND THAT MEDICARE, TRICARE, BCBSGA AND UNITED HEALTHCARE WILL ONLY ACCEPT BILLING THE FIRST LEVEL OUT WITH APPROPRIATE MODIFER(50,LT,RT) EACH ADDITIONAL LEVEL IS TO BE BILLED OUT SEPERATELY USING ADD ON CODES ALONG WITH ABOVE MODIFIER(50,LT,RT) AND ALSO ADDING MODIFER 59 TO ANY LEVELS AFTER THE SECOND ADD ON. OTHERWISE CLAIM WILL PAY LINE ITEM ONE AND TWO AND THE REST WILL DENY AS DUPLICATE AND MUST BE APPEALED. THEY WILL BE PAID BUT ONLY AFTER APPEALS PROCESS IS COMPLETE. HOPE THIS HELPS.
    64475-RT
    64476-RT
    64476-RT-59
    64476-RT-59

  12. Dr Kusuma Onkar Dsouza says:

    I work for Orthopedic Specilaity and I thought the correct way to code facet joint injections is:

    64475 – RT
    64476 RT x 4
    77003 – 26

    In case there has been lumbar facet joint injection done on the right side at 5 levels with fluoroscopic guidance.

    Now whats the actual way to code?
    Is it,

    64475 – RT
    64476 RT
    64476 RT – 59 x 3
    77003 – 26

  13. Patricia says:

    It is my understanding we should bill the primary code, then the add on code (once) with the number of units stating the number of levels.

  14. Linda Zukin CPC says:

    WPS, the Medicare carrier for MI, MN, IN, IL has said that they will only recognize the 50 modifier with qty 1. We list the additional bilateral levels separately.

    64475-50
    64476-50 x 1
    64476-50 x 1

  15. TOI D. says:

    I WORK FOR PAIN MANAGEMENT AND THE WAY I UTILIZE THOSE CODES ARE AS FOLLOW:
    64475 RT
    64476 RT 59 X3
    77003 26
    OR
    64475 50 59 X2
    64476 50 59 X2
    77003 26

  16. kala kulasingam says:

    THIS HAS BEEN A NIGHTMARE. I DO CODING FOR ASC(SOUTHERN CA). IN THE PAST ACCORDING TO CMS GUIDELINES FOR ANY BILATERAL PROCEDURES I LIST THE CODES TWICE WITH MODIFER 51 FOR SECOND LINE INCLUDING ADD ON CODES. I NEVER HAD ANY PROBLEM GETTING REIMBURSED BY MEDICARE(NHIC). WE DO LOT OF FACETS, TRANSFORAMINAL INJECTIONS. SINCE MIDDLE AUGUST OF 08 I HAVE BEEN GETTING REJECTIONS ON SOME OF THE LINES AS DUPLICATES. WHEN I CALL MEDICARE I AM GETTING DIFFERENT ANSWERS. SOME STATING MODIFIER 59 AND 76. READING THRU MEDICARE(PALMETTO) MANUAL FOR ASC IT STATES MODIFIER 59 BUT VERY VAGUE.

    NEED HELP WITH CODING!!!

  17. Suzanne Winter says:

    With regard to your statement in this article, “Do not bill multiple lines of CPT add-on codes +64472 and +64476″ then how can the provider bill for 3-4 different levels? We are accustom to seeing L3 as 64470-50, L4 as +64472-50, L5 as +64472-50. Are you saying the provider cannot bill different lines of the add-on codes to represent different levels? Did you want to say bill the number of add-on codes in units? I’m confused. Please clarify. Thanks Suzanne

  18. vikii Schmidt, CPC says:

    Podiatry Help :) Is it appropriate to bill CPT code 20550 x 3 ? Modifier -50 is not appropriate for this code & is done bilaterally sometimes twice each foot (metatarsophalangeal joints). We used to get paid for from NHIC & are now being denied.
    thank you,

  19. Pooja says:

    As per my knowledge,
    If facets were done at cervical region,
    00164470 LT/ RT / 50 -> (initial level ONLY)
    64470 LT / RT / 50; 64472-LT / RT / 50->(second / additional level)
    64470-LT / RT / 50; 64472- LT / RT / 50; 64472 X 1 to 5 units only – LT/ RT/ 50 (more than 2 levels upto 5 more levels) – 51

    If facets were done at thoracic region,
    00164470 LT/ RT / 50 -> (initial level ONLY)
    64470 LT / RT / 50; 64472-LT / RT / 50->(second / additional level)
    64470-LT / RT / 50; 64472- LT / RT / 50; 64472 X 1 to 10 units only- LT/ RT/ 50 (more than 2 levels upto 10 more levels) – 51

    If facets were done at lumber region,
    65575-LT/ RT / 50 -> (initial level ONLY)
    64475- LT / RT / 50; 64476-LT / RT / 50->(second / additional level)
    64475-LT / RT / 50; 64476 – LT / RT / 50; 64476 X 1 to 3units only- LT/ RT/ 50 (more than 2 levels upto 3 more levels) – 51

    If facets were done at sacral region,
    65575-LT/ RT / 50 -> (initial level ONLY)
    64475- LT / RT / 50; 64476-LT / RT / 50->(second / additional level)
    64475-LT / RT / 50; 64476 – LT / RT / 50; 64476 X 1 to 3units only – LT/ RT/ 50 (note: more than>2 levels upto 3 more levels only) – 51

    Note: use 77003 – 26 (for fluoroscopic guidance)

    Thank you,
    Pooja Javali

  20. Patsy Finch says:

    We had initially submitted a claim through clerical error to include 64483, 64475, 64476, 77003 when our patient had not discontinued anti-coagulation and this claim was filed without the V58.61- Florida Medicare rejected our claim as medically unnecessary. We refiled line item 64475, 64476, 77003 and now Medicare is rejecting for lack of dual diagnosis. Is there a dual diagnosis required for 64475, 64476 & 77003?
    Thank You,

    Patsy Finch

  21. Nikki says:

    How do you code a paravertebral facet block without fluoroscopy? Based on Medicare, this is considered a trigger point injection from 20551-20553. Is this correct?

  22. Pain Doc from VA says:

    I am in a desperate need of your help. After our coder of 18 years left on medical disability, we hired an online graduate coder and we don’t exactly know how to code for the following.

    Bilateral L3 and L4 facet medial branch block.
    Would it be 64475, 64475-50, 64476 x2 or would it be 64475-50,64476-50 or 64475-50, 64476×2?
    We asked three different coders and got three different answers.

    HELP!!!

  23. Douglas Wise, CPC says:

    I run a billing service in PA. We have submitted between 20-25k number of claims with these codes over the past 7 years. The bottom line is that it depends on the payer. Though I have always maintained that the code definition implies that the units designation reflects the number of additional levels and not the number of injections, many insurance claim offices are simply not sophisticated enough to understand a -50 modifier with 3, 4, 5, etc. in the units box. So despite the fact that the optimum scenario should be to bill one line item for the add-on with -50 modifier and units=levels, you will have to split the additionals onto separate lines for some payers. Check the medical/reimbursement policy of your payer; if they don’t publish one, call; if you get bad info from the call, you’ll know soon enough.

    For instance, PA Mcare is 1 line,-50, and units=levels; RR Mcare wants to see multiple lines, -50 on each, 1unit/level each; UHC same as PA, but doesn’t process correctly. Fortunately, UHC also allows LT/RT. Regarding modifiers, as several others have stated, add-ons are -51 exempt. In my opinion, -59 is also incorrect because this is the CCI modifier and as such is intended for different codes, not the same one on separate lines. I wouldn’t use it unless the policy specifically asks for it. We’ve had more success with -76 for repeat procedure; not perfect application, but more appropriate given same codes on different lines.

    My question for Pain Doc from VA, PA Mcare now has policy that: 1) no more than one additional level per day and 2) only four injections per year per level per side. Individual cases will be considered with documentation of course. Is this a reasonable expectation in your experience?
    (By the way, since Highmark is the J12 MAC, this will now include NJ, DE, MD, DC also)

    Best regards

  24. Angi says:

    I noticed that no one is using a 26 modifier for the professional component of a facet block. Is this no longer valid?

  25. ROSE says:

    How would you code median branch nerve lumbar facet block L2 thru S1
    I need to know how many levels you would assign. Does L5-S1 count as a level on medial branch nerve block, or woud it be:
    64475 L2-L3
    64476 L3-L4 = 3 total levels
    64476 L4-L5
    OR would it be:
    64475 L2-L3
    64476 L3-L4 = 4 total levels
    64476 L4-L5
    64476 L5-S1

  26. Cherie says:

    Does anyone have a cross reference for the new 2010 injection codes? My question is related to to 64470-64484. I need something to give to my physicians to help them transition from the old codes to the new codes.
    Thank you!

  27. Kathy says:

    Please over look any typing errors (rushing through)

    Ok, now before we (ASC) were not having any issues with this, but now we are.
    Bilateral rules that has just came out, stating to use 50 mod. (used to use single line method)

    EX for L3 and L5 bilateral injections:

    64475- (64493) -50 x 1 unit
    64476-(63394)-50 x 1 unit

    Rec denials stating that ASC can not use mod. 50 (per MLN MATTERS SE0742 January 1 2008, this is true, written CMS, get them off online).

    Now when you read MLN Matters MM6746 Dec. 4 2009, it states ASC Facet Injections 0213T…now we know that MCare doesn’t like HCPCS. leaves you with the question “Do we use 0213T? ”

    Now, reading MLN Matters MM6518 Aug. 31 09, it states under “Provider Types Affected” has “Physicians and Providers submitting claims to MCare”, you have to use the mod 50, and then goes on with the rules, but constantly uses the word “Physicians” like it is for physicians only, but at the beginning it states “Physicians and Providers”.

    Now, reading OIG, ooohhh, it just keeps getting better. Talks about the payment issues of using single line and states Physicians use mod 50 x units (according to injections), and talks how the ASC and Out PT Hospital fees are going to be different, but no answer, straight forward that is, “do we do the same method as the physicians or not”. OIG reads and includes ASC in the Sept. 2008 issue, so does that mean we are included to code that way?

    They came out with the Bilateral rule to stop payment issues, and then in the mean time, they are not making themselves clear.

    Oh, as a ASC in Ohio, we couldn’t use RT and LT for the single line injections, for that would have gotten rejected, we just use to code for Bilatereal, L3 and L5= 64475 and 64476 x 3, single lined and used this method for years.

    Any Ideals :)

  28. Kathy says:

    Part two:

    OOPS, I am so sorry for this being so long, but I am trying to help with who ever wants to read upon this, giving were the info is and what I have read so far (MLN Matters issues, and the OIG Sept. 2008 issue)

    In that, I did forget one more thing Coding Edge Magazine ( which I love to get my info from) in the Dec. 2008 issue it does state for us to use the mod. 50 method. it does state “Providers”

    Does anyone have any more info that might be able to help out here. I feel like, I have looked everywhere, and I don’t want to being doing this wrong. Maybe that is part of the confusion, tooo much info :)

    Just don’t know what way to fight for ???

  29. Mary says:

    Hi all,
    I wasn’t sure if anyone in this group could help or not…

    Can anyone tell me where we may find some talented coders that work with Facets ? We’re looking for someone with Facets Medicare Commissions and Billing configuration experience.

    They must have solid experience / ability to configure the Facets system for commissions, including schedules, arrangements, agents. Need to have knowledge of underlying tables and connections to billing. Knowledge of the CMS requirements would be helpful.

    Knowledge of the Billing applications and how to process Medicare billing. This includes billing groups, split billing etc. Knowledge of billing components and how those impact both billing and commissions.

    General Facets group set up experience would be helpful, along with understanding of basic batch processing.

    Do you happen to know anyone with these skills or a group that I can contact that works in this area? You can contact me directly at mjc@meridiangroup.com Thanks for your time!

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