# Medial Branch Blocks



## CynthiaT

I am new to coding pain management & find that I am confusing myself when it comes to determining what constitutes a 'level' for medial branch blocks.  Please help!  

 here is the op report:

*Procedure performed:*   Medial branch blocks for left L4-L5 and L5-S1 facet joints utilizing fluoroscopy.

*Description of the Procedure:*

The patient was identified. A written and verbal informed consent was obtained. Vital signs were evaluated and monitored throughout the procedure. IV access was obtained in the upper limb. Upon initiation of the procedure, the patient received 2 mg of Versed after being positioned prone on the fluoroscopy table in the OR. The skin overlying the lumbar and sacral region was thoroughly cleansed with Betadine solution and draped in a sterile fashion. Visualization of the lumbar and sacral region was obtained utilizing fluoroscopic imaging. Predicted locations as expected for medial branch nerves and dorsal rami of L3, L4, L5 were identified with fluoroscopy. The skin and the subcutaneous tissue overlying the predicted sites were penetrated and anesthetized with a 27-gauge 1.5-inch and 1% buffered lidocaine following negative aspirations for blood. Then, 22-gauge 3.5-inch Quincke spinal needles were then guided towards these locations on the left for medial branch blocks at L3, L4, and dorsal rami of L5 utilizing AP and oblique views. The procedures were performed at the transverse process of L4 intersecting with a vertebral body, the transverse process of L5 intersecting with the vertebral body and the sacral ala. Once it was determined that we were in the proper location, following negative aspirations for blood, the patient received as well amount of contrast Omnipaque 180 to ensure proper location and the absence of intravascular injection. The patient then received at each site less than 0.5 mL of injectate following negative aspirations for blood and and/or CSF at each of the three location. Injectate included a mixture of 2 mL of 0.75% Marcaine and 1 mL (6 mg/mL) of betamethasone. One the injections were performed, stylets were replaced in the needles and the needles were withdrawn. The skin overlying the injection site was thoroughly cleansed. Adhesive bandages were placed and the patient was returned to the recovery area where she received postprocedure instructions from the nursing staff in a written and verbal format. There was no evidence of intravascular or intraneural injection. There were no complications with the procedure. The patient was stable and ambulatory at the time of discharge.


_*So, would this be coded:  64493-LT, 64494-LT, & 99144*_
_*or:  64493-LT, 64494-LT, 64495-LT, & 99144*_

Thank you so much for your help!!!


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## cindyt

You should code this as 64493-LT, 64494-LT, 99144.  Your physician was working on two levels L4-L5 and then L5-S1.  Have a great New Year!


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## NaliniAAPC

Hi,
As per documentation performed levels  L4-L5 and L5-S1 (2 levels).so you need to code 64493-LT, 64494-LT, 99144 only.

Regards,
Nalini CPC


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## dwaldman

https://catalog.ama-assn.org/Catalog/cpt/issue_search.jsp

Above is the CPT Assistant page for back issues, in order for you to understand the coding from AMA/CPT perspective, it would be good idea to  order the following


Year: 2004 

Issue: September 

Ttle: The Facets of Paravertebral Facet Joint Procedures (64470-64476, 64622-64627) 

Below are some excerts from the article:

The paravertebral facet joint injection codes 64470-64476 should be reported per spinal level. Each vertebra in the spine is joined to the one above and the one below it by articular facet joints. There are four facet joints associated with each single vertebra in the spine below the level of C2 and above the level of S1. For example, at the L4 vertebral level, there is an L3-L4 facet joint at the upper end and also an L4-L5 facet joint at the inferior end.

Generally, each facet joint has dual innervation: one from the dorsal rami at the same level and one from the level above (eg, the L4-L5 lumbar facet joint is innervated by the medial branches of the dorsal rami from L3 and L4). Multiple injection levels are frequently performed when treating neck and upper back pain, as it is often difficult to isolate the exact joint level and two to three level injections may be performed at one sitting. Therefore, depending on the involved pathology, multiple-level facet joint and facet joint nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient.

 Unlike facet joint nerve (medial branch) codes used to describe facet joint injection (64470-64480), facet nerve destruction codes 64622-64627 refer to individual nerve level destruction. Thus, although injection of the left L3 and L4 medial (facet joint) nerve would be code as 64475, destruction of the L3 and L4 medial branch nerves would be coded as 64622 and 64623.

Here is another recent Q and A from CPT Assistant

Year: 2010 
 Issue: August 

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.


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