# Bilateral facet joint injection and bilateral lumbar medial branch blocks same day



## Melissa Harris CPC (Mar 15, 2016)

Hello,
I need some guidance on billing the following:

My physician performed bilateral facet Joint injections at L5-S1 and Bilateral Lumbar Medial Branch Blocks at L5-S1 at the same visit.   

How should I code this since they are at the same level?  

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management.


----------



## Walker22 (Mar 15, 2016)

Melissa Harris CPC said:


> Hello,
> I need some guidance on billing the following:
> 
> My physician performed bilateral facet Joint injections at L5-S1 and Bilateral Lumbar Medial Branch Blocks at L5-S1 at the same visit.
> ...



I don't see why both methods would need to be used. They both have the same result. I would code this as 64493.


----------



## dwaldman (Mar 15, 2016)

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

The code descriptor is plural with multiple injections that can occur for a given facet level on a single side or bilateral with modifier 50 but only one code is report per level treated (first level, second level, third & any addl.) , below is from past AMA CPT Assistants in which  they describe facet joint injections in conjunction with medial branch blocks at the same level as being reported per level with no additional reporting for multiple techniques utilized at that level.

_______________________________________________________________________________________

AMA CPT Assistant


May 2004 page 15


Coding Consultation:Questions and Answers

Nervous System, 64475 (Q&A) 

Question

The physician is performing multiple injections in L4-5. He is performing a medial branch lumbar facet nerve block, as well as facet steroid injections. He initially inserts a needle to a depth of 1.2 mm within the facet joint. He then injects Depo-Medrol into each facet joint (L3-4, L4-5, L5-S1) and removes the needles completely. Following this, the physician inserts another set of needles, this time to the tar points until the bone is reached in order to complete the nerve block. At this juncture, Marcaine is being injected, and once again the needles are withdrawn. Should code 64475 be reported more than one time for each injection? 

AMA Comment

From a CPT coding perspective, code 64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level, should be reported only one time for a facet injection at a specified level and side, regardless of the number of times the physician is sticking the needle at the same level. Therefore, it would not be appropriate to report code 64475 more than one time at the same level. 

______________________________________________________________________


AMA CPT Assistant

Rationale

September 2004 page 1

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

Example 3

The physician is performing medial branch lumbar facet nerve blocks as well as facet joint steroid injections using fluoroscopic localization (without contrast material). In performing this procedure, a needle is initially inserted within each facet joint. Then a steroidal agent is injected into each right sided facet joints of L3-4, L4-5, L5-S1 and the needles are completely removed. Another set of needles are inserted, this time targeting the medial branch nerves supplying the aforementioned joints (L2, L3, L4, L5). An anesthetic agent is injected over each of these medial branch nerves and once again the needles are removed. 


In this example, the facet injection codes 64475 and 64476 represent unilateral procedures reported once for injection(s) at a specific level regardless of the number of needle(s) inserted or number of drug(s) injected. Therefore, for this specific intervention, the following codes should be reported: 

Code 64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level, to describe the unilateral injections performed at L3-L4. 

Code 64476, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure), to describe the unilateral injections performed at L4-L5. 

Code 64476, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure, to describe the unilateral injections performed at L5-S1.


----------



## Venkatakrishnan (Mar 16, 2016)

Hi Melissa!

As per the description of CPT 64493, injection(s) performed (either) on the joint (or) nerves innervating that joint should be considered as single level only. As per the anatomy, Medial Branches are nerve fibers those innervate the facet joints. In order to relieve the pain, clinically the Physician has to either instill the medication around the nerve (Medial branch block) and / or inject the medications inside the joint capsule (Facet block). When both techniques are performed at a particular level (for instance L4-L5) pain arising at that level is controlled. The code description is based on the levels only not based on the techniques. 

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.

So reporting 64493 once for both nerve and joint injection is appropriate.


----------

