# Medial Branch Nerve Block at L4 and L5 Bilaterally



## Tvitolo

Please help with the levels :  OP note documentation

Using AP fluroscopy the right L5 facet joint was identified using a 25g needle, 3 ml of Lidocaine was injected overlying the base of the L6 facet joint.  Then a 22 ga inch spinal needle was advanced anteriorly util the bony contact was made at the L5-S1 facet joint under ap fluoroscopic view.  There was no parasthesia during the placement of the needle.  After negative aspiration for heme and csf, one ml of .5% lidocaine and 13mg of depomedrol was easily injected at the right L5 medial branch nerve without parasthesia.

This procedure was repeated for the right medial branch nerve block at L4 and Left medical branch nerve block at L4 and L5 with negative aspiration for heme and csf total of 80 mg of depomedral 

What CPT codes would you use

64493 RT and 64493 LT


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## dwaldman

L4 medial branch and L5 medial branch innervating the L5-S1 facet joint as seen below in AMA CPT Assistant, The procedure note you provided would support 64493 with modifier 50. See the MLN Matters article from CMS stating modifier 50 should be used with facet injections. If the carrier does not allow the reporting of the 50 modifier then you could as 64493-RT 64493-LT

AMA CPT Assistant August 2010 page 12

Surgery: Nervous System, 64490, 64491, 64492 (Q&A) 

Question: Lumbar medial branch blocks were performed on the right at L3, L4, and L5. Would codes 64490, 64491, and 64492 be reported because three different levels were injected? 

Answer: No. The L3, L4, and L5 medial branch nerves innervate the L4-L5 and L5-S1 facet joints. Therefore, code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level, is reported for the first joint injected or blocked (L4-L5). Code 64493 is reported for a single or initial level treated. Add-on code 64494, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure), is reported for the second joint or level injected or blocked (L5-S1). In this specific instance only, CPT codes 64493 and 64494 should be used, provided the injections were performed in the lumbar spine with fluoroscopic (or CT) guidance, as required to use codes 64490-64495. 

To further clarify, add-on code 64495, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure), is reported only once per day for injections at the third and any additional lumbar or sacral level(s) treated (which does not apply to this case). Codes 64494 and 64495 should only be used in conjunction with code 64493. 

CPT codes 64490-64492 are reported in the same way for cervical-thoracic facet injections or blocks. In addition, add-on codes 64492, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) and 64495 are reported once per day as a singular line item irrespective of the number of spinal levels treated. 

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"Physicians who perform facet joint injections on both the right and left sides of one level of the spine must use modifier 50 with the appropriate CPT codes when submitting claims."

www.cms.gov/Outreach-and-Education/Medicare.../MM6518.pdf


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