Coding and Billing Facet Joint Injections
Each spinal vertebra is linked to the vertebra above it and the vertebra below it by a pair of facet joints. These joints can be a source of back, neck, or extremity pain. The pain can be treated by injection into the facet joint. With the patient prone, and under fluoroscopic guidance, a needle is passed through the skin of the patient’s back into the facet joint. Contrast is used to visualize the anatomy and ensure correct needle placement. Then, a steroid/anaesthetic solution is injected into the joint.
Some patients may require a targeted medial-branch nerve block rather than a regular facet-joint block. Each facet joint is supplied by the medial branches of two different spinal nerves. For example, the facet joints at L2-L3 are supplied by medial branches from the L1 and L2 spinal nerves. For this reason, the physician must block two median nerves for each facet joint. In the case of a medial branch nerve block at L2-L3, for example, the physician would inject the medial branches of L1 and L2. For coding purposes, these two injections are considered a single injection service.
The following codes are used for facet-joint injections and medial branch nerve blocks:
Currently, the facet joint injections procedural codes are located in the nervous system section of the CPT® manual. The six codes are:
64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level
+64491 …second level (list separately in addition to code for primary procedure)
+64492 …third and any additional level(s) (list separately in addition to code for primary procedure)
64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
+64494 …second level (list separately in addition to code for primary procedure)
+64495 …third and any additional level(s) (list separately in addition to code for primary procedure)
Report 64490-64495 once per level, per side, regardless of the number of needle placements that are required. For instance, for injections performed on both sides of one vertebral level, report the base injection code (64490 or 64493) with modifier 50 Bilateral procedure. If a second level is injected bilaterally, report the add-on code (64491 or 64494), also with modifier 50.
Example: Under fluoroscopic guidance, a physician inserts two needles and injects medication around both medial branch nerves supplying the left L3-4 facet joint. Report 64493 for the unilateral injection.
Example: Under fluoroscopic guidance, a physician performs bilateral facet joint injections at L3-4 and L4-5. Report code 64493-50 for the bilateral injection at L3-4 and 64494-50 for the bilateral injection at L4-5.
OIG Findings of Incorrect Claim
Nearly two-thirds of the coding errors identified by the Department of Health and Human Services (HHS) Office of Inspector General (OIG) involved bilateral injections. In most cases, the physician reported a bilateral injection by listing the base code for the first side to code for primary procedure and the add-on code for the second side at the same level. For example, a bilateral single-level lumbar facet block was coded as 64493, 64494 rather than 64493-50. The overpayment is higher in cases where multiple levels were injected during the same encounter, which is a very common occurrence.
When reporting facet joint codes, you may not bill separately for the image guidance. Whether using fluoroscopy or computed axial tomography, guidance is required. If ultrasound guidance is used for the above procedures, the CPT® codebook states that you must report the facet joint injection using 0213T-0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance…. If no imaging is used, you must report 20552-20553 Injection(s); single or multiple trigger point(s)….
About the Author: Gouri Pathare MBBS, CPC, is a practicing medical professional with nearly 30 years of experience as an independent private medical practitioner in Mumbai, India, and has worked as a clinical specialist training coders for Episource India Pvt, Ltd., a United States-based KPO company.