Facet Joint Injections: Code with Precision
By G. J. Verhovshek, MA, CPC, director of Clinical Coding Communications
In a September 2008 report, the Office of Inspector General (OIG) revealed nearly two-thirds of facet joint injection claims it reviewed from 2006 did not meet Medicare program requirements. The report (“Medicare Payments for Facet Joint Injection Services,” OEI-05-07-00200) further asserts such claims resulted in “approximately $96 million in improper payments,” but also notes instances of undercoding and missed reimbursement opportunities.
As the OIG report explains, however, the shockingly-high error rate for facet joint injection claims stems primarily from two simple issues: confusion over when to apply add-on codes versus modifier 50 for additional injections and insufficient documentation to justify the services billed.
Injections of steroids and anesthetics into the facet joints between adjacent vertebrae may help identify the cause of back pain and temporarily ease back pain caused by arthritis or injury to the joints. Coding for this precise technique requires equally precise coding.
Define “Level” With Care
You should report facet joint/facet joint nerve blocks (64470-64479) per level rather than per injection. A level, in this case, refers to area between adjacent nerves (the joint) providing targets for injection. A single facet joint/facet joint nerve block level actually involves two separate nerves.
For example, if the provider administers diagnostic nerve blocks for C2, C3, and C4, she is addressing three nerves but only two levels (the joint at C2/C3 and the joint at C3/C4). Similarly, if the provider blocks the nerves from L2-L5, she is addressing four nerves (L2, L3, L4 and L5) but only three levels (the L2/L3 joint, the L3/L4 joint, and L4/L5 joint).
You should report one unit of 64470 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level for the initial level the provider injects in either the cervical or thoracic region. For each additional cervical or thoracic level the provider targets beyond the first, select add-on code +64472 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level (list separately in addition to code for primary procedure).
For the first lumbar or sacral level the provider addresses, you should claim 64475 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level. Apply add-on code +64476 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (list separately in addition to code for primary procedure) for each additional lumbar or sacral level the provider injects. For example, if your provider injects the C3/C4 and C4/C5 facet joints, report 64470 for the initial injection, plus one unit of +64472 for the additional cervical level. If your provider instead targeted levels L1/L2, L2/L3 and L3/L4, you would report 64475 (for the initial lumbar level) and +64476 x 2 for the two additional levels (L2/L3 and L3/L4).
When to Use Modifier 50
Under Medicare rules, you should append modifier 50 Bilateral procedure to the appropriate facet joint/facet joint nerve block code(s) if the provider administers injections on both the left and right side of the spine at the same level. CPT® specifically defines 64470-64476 as unilateral procedures. That is, the code descriptors assume the provider targets the joint on either the left or right side.
The OIG report found that in almost 5 percent of the claims it reviewed, providers billed for unilateral services when they had actually performed bilateral services, “resulting in a 50 percent underpayment.”
If the provider injects the L4/L5 and L5/L6 facet joints on both the left and right, for instance, you should claim 64475-50 (for the bilateral injection at the first level) and +64476-50 (for the bilateral injection at the additional level). You should never report add-on codes +64472 or +64476 for additional injections at the same facet joint/facet joint nerve level, whether the additional injections occur on the same, or opposite, side of the spine.
For same-level injections on the opposite side of the spine, you would append modifier 50, as described above.
Because CPT® describes facet joint/facet joint nerve codes as “per level” rather than “per injection,” you would use a single code to describe two or more same-level injections on the same side of the spine. For example, the provider may administer a left-side C4/C5 intra-articular injection via a single needle puncture, or he may administer two separate injections to the medial branch nerves supplying the C4/C5 facet joint. In either case, report a single unit of 64470.
The L5/S1 facet joint level receives innervation from three nerves (the L4, L5 and S1 para-vertebral facet joint nerves). If your provider blocks each of these nerves with a separate injection, you must report a single unit of 64475 because she has addressed only one level (L5/S1).
Guidance May Be Separate
If the provider uses fluoroscopic guidance for needle placement and also provides the interpretation and report, you may report 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction with modifier 26 Professional component appended. The OIG report explains, “Physicians typically perform facet joint injections using radiological guidance to ensure correct needle placement and avoid nerve or other injury.”
You should report 77003-26 only once per session, regardless of the number of injections the provider administers.
Documentation Is a Must
According to the OIG, 38 percent of faulty facet joint injection claims its surveyed lacked adequate documentation to support the services billed. Insufficiencies ranged from a total absence of documentation to missing details, “such as which levels and sides of the back, were injected,” explains the OIG report.
In this case, the solution is simple: Providers should carefully document the location of each and every injection, including the level(s) injected, the total number of injections per level, and on which side of the spine the injection(s) took place.
For instance, the provider might document, “Two facet joint nerve injection at right side C4/C5 and two facet joint nerve injections at left side C4/C5.” Not only will this satisfy documentation requirements, it will lead to more accurate coding (in this case, 64470-50 and +64472-50).
View the OIG’s “Medicare Payments for Facet Joint Injection Services” in full.
Facet Joint Injection Basics
Facet joints are joints in the spine that help stabilize and allow the spine to bend and twist. Facet joint/facet joint nerve injections are an interventional pain management technique providers may use to diagnose or treat back pain. The purpose of the injection (therapeutic or diagnostic) does not affect coding.
To perform a diagnostic service, the provider injects a numbing medicine and/or a steroid into one or two suspect facet joints. Depending on the whether the patient experiences pain relief, the provider can confirm (or eliminate) the injected facet joint(s) as the source of pain. For a therapeutic injection, a provider injects a numbing medicine and/or a steroid into one or more facet joints to reduce inflammation.
Typically, a provider performs a diagnostic injection once, whereas he might provide therapeutic injections repeatedly for ongoing pain relief.
Most Medicare payers place frequency limitations on facet joint/facet joint nerve block codes 64470-+64476, although the limitations are not necessarily consistent from payer to payer. Check with your carrier for its individual limitations, especially if the provider bills for six or more injection levels for the same patient within six months.