# MBB Inj and RF



## 574coding (Mar 20, 2014)

Hello,
I am newer to pain management coding and I was hoping for some insight coding MBB 64490-64495 and RF 64633-64636.

If the provider list L2, L3, L4 we would code levels at L3-L4 and L4-L5.  If they have L3-L4, L4-L5 or L3/4, L4/5 we would stick with this level due to the reference of the facet joint and not the nerve.   The  lumbar area nerves meet one level below at the facet joint. 

It would be the same as lumbar for thoracic level-the nerves meet one level below at the facet joint.

For cervical, it would be the level they note because in the cervical area, the nerves go up.  C3, C4, C5 would be C3-C4 and C4-C5 or if they note the facet joints C4-C5, C5-C6 or C4/5, C5/6 that would be the levels we code.

Thank you for your time.


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## kseeg23 (Mar 20, 2014)

To whoever answers the above question, I have an additional one. If the Dr does a 2 level unilateral medial branch block, exactly how many needle pokes/injections is there?


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## dwaldman (Mar 21, 2014)

574coding, I believe the current interpretation that you describe would accurately capture the coding for the procedures in question.

Kseeg23, the AMA CPT Assistant article describes three separate needle placements for L3, L4, L5 to treat two levels L4-L5 and L5-S1.

Another common examples, would be four separate needle placements for unilateral procedure of L2,L3,L4,L5 to encompass three levels: L3-L4, L4-L5, L5-S1
__________________________________________________________
September 2004 page 1

The Facets of Paravertebral Facet Joint Procedures (64470-64476, 64622-64627) 
 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. 
For example, a left-sided L4-L5 intra-articular injection performed with a single needle puncture would be coded as 64475. Injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would also be coded as 64475, even though two separate injections are performed to effect the same result. 

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 rightsided 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. 

Rationale

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. 

Code 76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction. The fluoroscopic localization for needle placement is described by code 76005 appended by modfier 26. The CPT professional component modifier 26 is appended. CPT code 76005 is intended to be reported once per spinal region (eg, cervical, lumbar) and not per level. 


Facet Joint Nerve Anatomy

Each facet joint is supplied by two medial branch nerves. As each main spinal nerve exits the spine and passes through the intervetebral foramen of the spine, it gives off a branch (posterior primary ramus) that supplies the structures at the back of the spine, while the main spinal nerve (anterior primary ramus) continues onward to supply peripheral structures. The posterior primary ramus then typically divides into three branches: medial, intermediate, and lateral. Each medial branch supplies sensation to one half of each facet joint above and below the spinal nerve of origin, the multifidus muscle, the spinal ligaments, and a small area of skin in the midline of the back. The intermediate and lateral branches supply back muscles farther away from the midline. 





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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## 574coding (Mar 24, 2014)

dwaldman Thank you so much for your reply!


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