Anesthesia Coding Alert

CPT Codes 2000 deleted two codes (64442 and 64443) for facet joint injections and replaced them with four new codes (64470-64476) as well as a new fluoroscopy code. Last year, the Centers for Medicare & Medicaid Services (CMS, formerly HCFA) also revised its regulations to permit billing for bilateral injections.
     
Although many of these changes were welcomed by pain management physicians and their coders, they have been the source of much confusion, in part because not all carriers have published new local medical review policies (LMRPs) that reflect the changes. Many LMRPs, even those that have been revised, include complicated guidelines that govern how and when such injections may be billed.
Diagnostic and Therapeutic Injections  
The term "facet joint injection" describes two distinct, although related, procedures. The first, sometimes referred to as an intra-articular block, involves the injection of anesthetic and/or steroid to denervate temporarily the paravertebral facet joint, which Coders' Desk Reference defines as "the bony surfaces between which vertebrae articulate with each other." In the second procedure, the injection is made into the facet joint nerve, often referred to as the median branch nerve. Both injections require fluoroscopic guidance.
 
Facet joint and median branch nerve injections are performed for two reasons. The first -- and, according to many LMRPs, the most important -- is as a diagnostic tool. The injections are used to document or confirm suspicions of posterior elemental biomechanical back pain by helping to determine whether a joint has structural abnormalities. Once the pain has been blocked, the patient may be asked to perform the same activities that usually aggravate the pain, and record any effects. The absence of lower back pain after the injections suggests that the facet joints are the source of the symptoms.
 
The injections may also be used therapeutically to provide temporary pain relief that may facilitate other types of treatment, such as physical therapy. Usually, these injections are given only to patients whose back pain is neither disc-related nor radicular (i.e., related to nerve roots).
Coding the Procedures  
CPT includes the following four codes to report facet joint injections:
  64470 -- injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level
  
64472 --  ... cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
  
64475 --  ... lumbar or sacral, single level
  
64476 --  ... lumbar or sacral, each additional level (list separately in addition to code for primary procedure).    
Codes 64470 and 64475 describe different locations [...]