Neurosurgery Coding Alert

Question: The neurosurgeon injected a diagnostic agent into the patient’s facet joint at two levels of the cervical region. He used imaging fluoroscopy imaging guidance. Which CPT^® codes should I report for this service?

Ohio Subscriber

Answer: You should report 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)) and +64491 (... second level (List separately in addition to code for primary procedure)) on your claim.

Don’t miss: You should report 64490 for the first injection the surgeon performs on the cervical or thoracic region of the spine. You should report +64491 when the surgeon performs an injection on a second level of the cervical and/or thoracic region during the same encounter.