Anesthesia Coding Alert

Question: When a facet joint nerve injection is done by blocking the medial branch nerves (two nerves injected for each joint), should two levels be billed (two injections equals two levels)? Also, should facet injections be billed bilaterally? Nebraska Subscriber Answer: The issue of what constitutes a "level" as described in the CPT book is disputed among coding experts. Most carriers' local medical review policies (LMRPs) do not provide any detailed definition. Only the LMRP for AdminiStar Federal, which administers Medicare programs in Kentucky and Indiana, specifically states that the two medial branches that supply a single facet joint equal one level.

One opinion is that the relative value units (RVUs) associated with this code, which incorporate work, risk and use, are for one injection into the facet joint. Therefore, if the pain management physician performs two injections to block the two nerves that supply the actual facet joint, logic should support billing for two levels.

A frequent coding scenario for facet joint nerve injections involves the lumbar or sacral segment of the spine. The associated CPT codes for these injections are 64475 (Injection, anesthetic agent and/or steroid, paraver-tebral facet joint or facet joint nerve; lumbar or sacral, single level) and +64476 ( lumbar or sacral, each additional level [list separately in addition to code for primary procedure]). The code range for introduction/injection of anesthetic agent (nerve block) for diagnostic or therapeutic purposes is 64470-64475, whereas 64622-64627 define facet joint nerve destruction by neurolytic agent (e.g., chemical, thermal, electrical, radiofrequency or chemodenervation).

According to many carriers' LMRPs, numerous diagnoses support medical necessity. The most common are spondylosis without myelopathy (cervical, 721.0; thoracic, 721.2; and lumbar, 721.3) and lumbago (724.2). Facet joint injections can be billed bilaterally with modifier -50 (Bilateral procedure) if the documentation supports the separate injection on the bilateral side. The use of modifier -50 varies by payer. Some prefer one line item, others prefer two line items, and some require the LT (Left side) or -RT (Right side) modifiers. Responses to You Be the Coder and Reader Questions were provided by Marvel J. Hammer, RN, CPC, of MJH Consulting in Denver.