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Facet joint injection

  1. Default Facet joint injection
    Medical Coding Books
    I HAVE A CLAIM THAT KEEPS DENYING FOR NON COVERED SERVICES BECAUSE THIS IS NOT DEEMED A MEDICAL NECESSITY BY THE PAYER.
    CAN ANYONE HELP ME WITH THIS? I USED 64475 RT & 64476 RT WITH DIAGNOSIS 716.98 AND 724.2. HERE IS THE OP NOTE:

    PREOPERATIVE DIAGNOSES:
    1. Degenerative lumbar scoliosis with right concavity.
    2. Status post right total knee replacement January 2008.
    3. Chronic low back pain.

    PROCEDURE: Facet joint injections.

    ANESTHESIA: Local.

    INDICATIONS: This lady had a facet block with good relief in the past. She also had a lumbar epidural steroid injection with no relief. She is here today to have facet blocks after clinical exam and palpation. She complains mainly of pain at the level of L2-L3 on the right side and also at the level of L4-L5 on the right side. Those areas being in the concavity of her degenerative lumbar scoliosis and given her problems because of the hyperpressure and her overweight situation.

    OPERATIVE PROCEDURE: After prepping and draping of the patient's back, I used the C-arm and I located the facet joint at L2-L3 and I placed my spinal needle in the facet joint. I injected a solution of 2 cc of Depo-Medrol mixed with 3 cc of normal saline in and around the facet joint. Then I moved to L4-L5 on the right side and again I placed my needle under C-arm guidance in the facet joint of L4-L5 on the right and I injected also a solution of Depo-Medrol 2 cc mixed with 3 cc of normal saline. She tolerated the procedure well. I will see her back in the office in two months.

  2. #2
    Default
    I suggest you look at that payer's LCD or medical policies regarding this procedure. It sounds like you are not using a diagnosis code that is approved. I bill these injections all the time, and those codes are not on the list of approved diagnoses.
    Walker Bachman, CPC, CPPM

  3. #3
    Default
    Also, I don't see the scoliosis DX which would be in the 737.3X area. Definitely check the carrier policies for this procedure.

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