Anesthesia Coding Alert

Carefully choose 64470 or 64626 based on MD's documentation.

Facet joint injections are anything but a piece of cake for coders. There's a difference between a nerve block and nerve destruction. There's also a difference in the definition of the term "level" for nerve blocks or nerve destruction in the CPT code descriptions. Refresh your memory on how to code these two tricky procedures to ensure your pain management specialist is getting her due.

Beware Miscounting Nerves vs. Joints

A single level for paravertebral facet joint injections deals with the interspace -- or "joint" -- between two vertebrae, so one level of block will actually involve an injection into the joint itself, or two injections blocking each of the paravertebral facet joint (medial branch) nerves that provide sensory information from the joint back to the spine.

Example 1: Your pain management specialist performs diagnostic nerve blocks of the C3 and C4 medial branches (blocking the C3-C4 facet joint) -- that is only one level. You should report only 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) for those injections, says pain management specialist Richard Kennedy, MD.

Example 2: Now let's say your pain management specialist performs injections of the C3, C4, and C5 medial branches. Now she is addressing three nerves but only two "joints;" that is, C3-C4 and C4-C5.  You would count each joint as one level, so use +64472 (. . . cervical or thoracic, each additional level [List separately in addition to code for primary procedure]) for the second injection.

Pop quiz: Test your nerve block counting skills with this quick story problem: Your pain management specialist hands you documentation that shows she blocked the L1 through L4 medial branches on a patient. How many levels should you code for the procedure?

Answer: Three. Your pain management specialist is addressing four nerves: L1, L2, L3, and L4. However, since you count only the interspaces between the vertebrae, you would code only three levels: one for the joint between L2-L3, a second for the joint between L3-L4, and your third for the joint between L4-L5. So you would report 64475 first, and add two units of +64476. You many have noticed that the nomenclature from the nerve to facet joint level changed in the example. For instance, the L1 and L2 medial branches provide the sensory innervation from the L2-L3 facet joint level. This is because there is a C8 spinal nerve but no C8 vertebrae. So in the cervical region, the medial branches "match" the facet joint level " that is, C3 and C4 for the C3-C4 facet joint level. On the other hand, the T3 and T4 medial branches provide innervation to the T2-T3 facet joint level. Likewise, the L3 and L4 facet joint nerves provide innervation to the L2-L3 facet joint level.

Use Caution Tallying Levels vs. Injections

Remember, "per level" does not equate to "per injection." This is an important distinction, because your pain management specialist might perform facet joint nerve injections that require more than one injection per level, in comparison to a single injection into the facet joint itself, which equates to one level.

Example 1: Your pain management specialist provides a left C4-C5 intra-articular facet joint injection via a single needle puncture; or, he gives two separate injections to the C4 and C5 medial branch nerves supplying the C4-C5 facet joint. In either case, you should report a single unit of 64470.

Example 2: The L5-S1 facet joint level receives innervation from the L4 medial branch and the L5 dorsal ramus, both considered paravertebral facet joint nerves. If your pain management specialist blocks each of these nerves with a separate injection, you will still report only one unit of 64475, because he has addressed just a single level (L5-S1). The coding would be the same if he injected directly into the L5-S1 facet joint with a single injection.

Distinguish Nerve Blocks from Destruction

When you code for facet joint injections, be sure to examine the documentation carefully to figure out if your pain management specialist performed a nerve block (64470-+64476) or more extensive nerve destruction, which merits the following codes:
• 64622 -- Destruction by neurolytic agent, paraver-  tebral 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).

Count nerves: When you report for facet joint nerve destruction, count the actual number of nerves that the physician destroys by a neurolytic agent. For codes 64622-+64627, one "level" will equal one nerve.

For example, if your pain management specialist documents "C4 and C5 facet joint nerve radio frequency destruction," you would report 64626 for the first nerve/level (C4) and one unit of the add-on code +64627 for the additional nerve/level (C5), Kennedy notes.

Remember Fluoroscopic Guidance

If your pain management specialist uses fluoroscopic guidance for needle placement -- for either facet joint nerve block or destruction, then report 77003 (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). Append modifier 26 (Professional component) if the procedure is performed in a facility site of service, meaning place of service code 21 (Inpatient hospital), 22 (Outpatient hospital), or 24 (Ambulatory surgical center). Report 77003 only once per region, regardless of how many facet joint procedures the provider performs.

Watch for: In order to report 77003 compliantly, your physician should include documentation stating that he used fluoroscopic guidance for the procedure, says Stacy Gregory, RCC, CPC, owner of Gregory Medical Consulting Services in Tacoma, Wash.