Coding and Billing Facet Joint Injections

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.

Image Guidance

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.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

13 Responses to “Coding and Billing Facet Joint Injections”

  1. barnali says:

    Thank you Mr. john for this publication 🙂

  2. annie says:

    Radiofrequency ablation performed at L3-L4, L4-L5,L5-S1 would this be coded as
    because L5-S1 is innervated by L4-L5?

  3. Tracie says:

    I have a question regarding Facet Joint injections and hope you can help. The physician indicates Medial Branch Nerve block left L3, L4, L5, sacral ala. Would the sacral ala be considered a nerve level? I’m not sure if I would code this as a 2 level or 3 level block. I am reading in some places that the sacral ala is NOT a facet joint and should not be included. So, I am confused as to whether this would be a 2 level block with a sacroiliac injection or a 3 level block. I would appreciate your help

  4. Norma says:

    Hi, I work for a Dr.’s office that does Trigger Point injections.(20553) Recently I researched how many trigger points can be done in one setting and the modifier if there is one for multiple . I then was lead to a screen that informed me that a regulation was changing starting March 1, 2017 stating that trigger point (20553) will be denied on the third injection if it is within 90 days. Can I please get some clarification on that regulation. I cannot locate those specifics anywhere.

  5. Tammy says:

    NORMA can you direct me to the information on trigger points .. please I am trying to find a good article or resource that can help me with billing injections

  6. Cheryl Tribley says:

    Our doctor does facet joint injections with no imaging guidance. I understand that the CPT code would be 20552 in this case, but what would the diagnosis be then? Normally for a facet joint injection we would use spondylosis, but not sure that will get paid with a trigger point injection. Help!

  7. Daniel A Webb says:

    I am looking at a Health Insurance Claim Form with the following CPT codes and charges
    64490 $5,900
    64491 $2,250
    64492 $2,250
    These appear high to me. Please provide your comments. Thank you

  8. Patty Dykes says:

    Were can I find a article from Medicare or CMS to show that Medicare will only pay for the first injection for the ASC for procedure codes 64493, 64494, 64495. Please let me know about this billing for the Ambulatory Surgical Center.

  9. Cristina says:

    Im looking for DX for 64493 B/L. I have billed 64493 with medicare DX M5416 and serval others and still no luck please help. Anyone

  10. Michelle says:

    I have noticed that medicare is denying all 64493, 64494. 64495 with modifier 50, since the Jan 2019. Has anyone else had this issue? I am using ICD M43.06.

  11. Rae Vance says:

    Where can I find documentation / the resource that directs us to use CPT 20552/20553 for a facet injection when no imaging is used? Thank you.

  12. Lynn says:

    For 64493 we use ICD M47.817.

  13. Devyn Berube says:

    The charging for these services has been changed for 2020. Can this article be updated to reflect how to charge out the add on codes? AMA now states not to use the modifier 50 on the add on codes and to submit them as separate lines if performed bilaterally.