Sharpen Your Facet Joint Intervention Coding

All along the back of the spine, at each level, a pair of small facet joints connects the vertebrae — the bony building blocks of the spine — holding the vertebral column together and providing support. These small joints may become inflamed due to a variety of conditions including osteoarthritis, disc degeneration, spinal stenosis, or from trauma such as a car accident.

When the facet joints become swollen and enlarged because of injury or arthritis, it causes pain. If the affected joint is in the neck, it may cause headaches and difficulty moving the head. If it is in the back, it may cause pain in the lower back, buttocks, or legs.

In cases where conservative approaches, such as anti-inflammatory medications, chiropractic manipulation, and physical therapy, don’t provide sufficient relief, denervation or injection into or around the facet joint may help alleviate the pain.

Examine the Anatomy

To better understand these techniques, let’s review some anatomy. A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. The facet joint is noted at a specific level by the vertebrae that form it (e.g., C4-5 or L2-3). There are two facet joints at each level, left and right, and there are 28 levels of facet joints. They lie in between the vertebrae, on either side of the vertebral body. These tiny joints allow the spine to bend and twist and keep the back from slipping too far forward or twisting without limits.

Each facet joint is supplied by the medial branches of two different spinal nerves. Two to three medial branch nerves innervate each lumbar facet joint, and two nerves innervate each cervical and thoracic facet joint. These nerves are branches of the posterior division of the spinal nerves, located immediately above and below the joint.

For example, innervation of the facet joints at L4-L5 is supplied by medial branches originating from the L3 and L4 spinal nerves. As such, the physician must block two median nerves for each facet joint. In the case of a medial branch nerve block at L4-L5, the physician would inject the medial branches of L3 and L4. For coding purposes, these two injections are considered a single injection service.

Relief Is an Injection Away

The facet block procedure is an injection of local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the nerve supply to the joint (medial nerves) known as medial branch block (MBB).

For intra-articular injections, the patient is in the prone position, and the physician uses imaging guidance — X-ray (fluoroscopy) or computed axial tomography (CT) — to ensure accurate placement of the needle for injection. The doctor directs a very small needle through the skin of the patient’s back into the facet joint and injects a small amount of contrast dye to verify that the needle is in the joint. Following this confirmation, local anesthetic (i.e., Lidocaine), with or without an anti-inflammatory medication (steroid), is slowly injected into the joint. Some patients, however, may require a targeted medial branch nerve block rather than a regular facet joint block to achieve pain relief.

Coding Facet Joint Interventions for Pain Management

Currently, the procedural codes for facet joint injections are located in the nervous system section of the CPT® code book. Use the following six codes for facet joint injections and medial branch nerve blocks:

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)

Facet joint denervation is another interventional technique physicians use to treat central neck or back pain caused by arthritis in or injury to the facet joints. The procedure involves using a special needle with a heated tip to destroy the nerves that supply the joints. Use the following codes for facet joint denervation:

64633    Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

+ 64634               each additional facet joint (List separately in addition to code for primary procedure)

64635    Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

+64636                 each additional facet joint (List separately in addition to code for primary procedure)

Note Coding Guidelines

When reporting facet joint interventions, consider the following coding guidelines:

• Codes 64490-64495 are unilateral procedures.
• Use CPT® codes 64490 and 64493 to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
• Use CPT® add-on codes 64491, 64492 and 64494, 64495 to report second and third additional levels of paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them.
• Report 64490-64495 once per level, irrespective of the number of drugs injected or whether single or multiple punctures are required to anesthetize the target joint at a given level and side.
• Append modifier KX Requirements specified in the medical policy have been met to the line for all diagnostic injections.
• Append the bilateral modifier 50 to the appropriate code when the provider performs bilateral injections/denervations.
• Do not append multiple procedures modifier 51 to +64491, +64492, +64494, or +64495 because these are add-on codes and exempt from multiple procedure concept.

When your provider performs injections on both sides of one vertebral level, report the base injection code (64490 or 64493) with modifier 50 Bilateral procedure. If the physician injects a second level bilaterally, report the add-on codes twice. Per the CPT® code book, “Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495.”

Example 1: 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 therapeutic injection.

Example 2: 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 twice for the bilateral injections at L4-5.

Understand the Nuances of Imaging Guidance

Because of the diagnostic nature of facet blocks, precise localization is necessary. Thus, imaging guidance (fluoroscopy, CT) and injection of contrast are inclusive components of 64490-64495 and not paid separately. In other words, when reporting facet joint codes, you may not bill separately for the image guidance when done via fluoroscopy or CT. If the doctor uses ultrasound guidance for the above procedures, the CPT® code book 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….

OIG Finds Improper Payments for Facet-Joint Denervation

Recently released audit findings from the Department of Health and Human Services (HHS) Office of Inspector General (OIG) show that Medicare did not pay physicians for selected facet-joint denervation sessions in accordance with Medicare requirements. Due to inadequate oversight, the Centers for Medicare & Medicaid Services (CMS) improperly paid physicians a total of $9.5 million for certain facet-joint denervation sessions. Based on OIG recommendations, CMS plans to:

• Direct the Medicare Administrative Contractors (MACs) to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions;
• Instruct the MACs to notify the physicians who received potential overpayments so they can exercise reasonable diligence to identify, report, and return any overpayments per the 60-day rule;
• Assess the effectiveness of oversight mechanisms specific to detecting or preventing improper payments to physicians for facet-joint denervation sessions and modify the oversight mechanisms based on that assessment; and
• Direct the MACs to review claims for denervation sessions after the OIG’s audit period (dates of service from January 2019 through August 2020) to recover any improper payments.

This highlights the importance of verifying with your MAC the limitations of coverages to avoid inappropriate billing for and overuse of spinal facet-joint denervation for pain management.

For more information, see the OIG report at oig.hhs.gov/oas/reports/region9/92103002.pdf.

CMS provides additional guidance on billing and coding facet joint interventions for pain management on their website; see article A57787.

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Stacy Chaplain

Stacy Chaplain, MD, CPC, is a development editor at AAPC. She has worked in medicine for more than 23 years, with an emphasis on education, writing, and editing since 2015. Chaplain received her Bachelor of Arts in biology from the University of Texas at Austin and her doctorate in medicine from the University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Ore., local chapter.

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