Anesthesia Coding Alert

Question: Our pain management physician performs unilateral facet injections, but he would like to start administering bilateral injections on some patients. How should I report the bilateral procedures?


Oregon Subscriber

Answer: There are several ways to code bilateral facet injections. Report the injection with 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level). Append a modifier to designate that it is a bilateral procedure. Most carriers require modifier -50 (Bilateral procedure) for this.

Be sure to document clearly that you're reporting separate injections so the carrier will reimburse you for both; you should get paid 150 percent of the usual fee for a single injection.

Another option comes into play when the carrier wants you to designate bilateral procedures by appending modifiers -LT (Left side) or -RT (Right side) to the procedure code. United Healthcare and Medicare prefer that you report bilaterals this way.