Anesthesia Coding Alert

If your practice is like many offices incorrectly reporting facet joint injections, now's the time to fix your errors -- or you could be facing major payback requests.

63 percent of facet joint injections allowed in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments for physician services, according to a September 2008 OIG report. Associated facility claims had an additional $33 million in improper payments.

Lumbar facet joint nerve neurolytic destruction indications include intervertebral lumbar disk disorder or degeneration with myelopathy, lumbar spondylosis with myelopathy, nerve root disorders, postlaminectomy syndrome, spinal stenosis, lumbago, and congenital anomaly of the spine, said Linda Van Horn, MBA, at a conference of the Society for Pain Practice Management in Phoenix, on March 30.

For the indications above, you will use:

• 64622 -- Destruction by a neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level

• +64623 -- ... lumbar or sacral, each additional level.

Tip: For facet joint nerve destruction, coding is based on each nerve.

Example: Report the destruction of facet nerve L4 and L5 as two levels. Use codes 64622 and one unit of +64623. Payers vary in the maximum number of nerve destruction allowed on one date of service and diagnosis that meet medical necessity. Check the individual payer policy for coverage.

Anesthetic agent and/or steroid facet are billed differently than neurolytic facet. Trying to bill them the same way will earn you a denial.

Bill anesthetic agent and/or steroid facet per level. These codes for anesthetic and steroid facets differ when it comes to distinguishing between lumbar, sacral, cervical, and thoracic nerves:

• 64470 -- Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

• +64472 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

• 64475 -- ... lumbar or sacral, single level

• +64476 -- ... lumbar or sacral, each additional level

Neurolytic facets, on the other hand, are billed per nerve. There is a difference in levels for these lumbar, sacral, cervical, and thoracic neurolytic facet codes:

• 64622 -- Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level

• 64623 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

• 64626 -- ... cervical or thoracic, single level

• +64627 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure).

Lumbar facet joint and facet joint nerve procedures are unilateral. You can bill these procedures bilaterally. Use modifier 50 (Bilateral procedure), says Van Horn,who is CEO of 21st Century Edge, a pain management practice management consulting firm in Kansas City, Mo.

Careful: Some payers require the use modifiers RT (Right side) and LT (Left side), rather than modifier 50. Bilateral lumbar neurolytic facet reimburses at 150 percent of base reimbursement, Van Horn adds.

Do not include modifier 51 (Multiple procedures) on add-on codes. For example, you cannot append modifier 51 to +64472 or +64476.

Intra-articular facet joint injections are commonly documented at facet joint level -- for example, a right L4-L5 facet joint injection or a left C6-C7 intra-articular facet injection. Whereas physicians more frequently document facet joint nerve injections (a.k.a. medial branch blocks) per nerve, such as right L3 and L4 medial branch block or left C6, C7 facet joint nerve injections.

Each facet joint level, i.e. C6-C7, has sensory innervation from two facet joint nerves, such as the C6 and C7 medial branches. Compliant coding requires facet joint injections be based on facet joint level, not per each individual nerve injected, hence a C6-C7 intra-articular facet joint injection = 1 injection code (64470). Injections of the C6 and C7 facet joint nerves (two needle placements and two injections) = 1 level = 1 injection code (64470). Compliant coding of facet joint nerve destruction procedures however are reported based on each individual nerve rather than the facet joint level.Hence, radio frequency destruction of both the C6 and C7 facet joint nerves would be reported with two codes, 64626 and 64627.

Lumbar facet injection codes 64475 and +64476 are used for two different blocks -- an injection into the interarticular facet joint and facet nerve injections, also known as medial branch blocks. There are two medial branches that innervative each facet joint, so physicians will need to perform two injections to block one joint, three injections to block two joints, and so on.

The number of nerves injected is n-1 to the number of levels. The payer will expect the documentation of a medial branch block to indicate the levels injected, not the number of nerves.