Neurosurgery Coding Alert

Recent Medicare and CPT revisions have increased confusion for physicians administering facet joint injections, especially when they provide more than one injection for the same patient on the same day. By carefully examining your payers' guidelines and applying modifiers judiciously, you can guarantee that you will receive the compensation you deserve. Know the Codes and Procedures In 2000, CPT eliminated two codes (64442 and 64443) for facet joint injections and introduced four new codes:

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). The above codes, as well as the term "facet joint injection," actually describe two distinct but related procedures, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. The first type of injection, often referred to as an intra-articular block, involves injecting an anesthetic and/or steroid to denervate the paravertebral facet joint (the bony surface between vertebrae). In the second procedure, the physician targets the facet joint nerve, correctly called the median branch nerve. Either type of injection can be diagnostic (the most common use) or therapeutic. As a diagnostic tool, the physician uses the injections to document or confirm diagnoses of posterior elemental biomechanical back pain caused by structural abnormalities. The physician administers the injection to block the pain. The patient then performs the same activities that usually aggravate his or her back pain, and the physician records any effects. The absence of lower back pain after the injections suggests that the facet joint(s) is the source of the problem. Therapeutic injections provide temporary pain relief to facilitate other types of treatment, such as physical therapy. Generally, physicians administer such injections only when pain is neither disc-related nor radicular, i.e., related to nerve roots.

Note: You should report phenol (or other neurolytic) destruction of the paravertebral facet joint nerve with 64622-64627. These injections should not be confused with the nerve block, which has only a temporary effect. Reporting Multiple Injections Report the initial injection using either 64470 (cervical or thoracic) or 64475 (lumbar or sacral) as appropriate to location, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM Program Coordinator at Clarkson College in Omaha, Neb. Report each additional level with a single unit of either +64472 or +64476, again as appropriate to location, i.e., +64472 must accompany 64470, and +64476 must accompany 64475. You may report multiple units of +64472/+64476 per session, as [...]