Anesthesia Coding Alert

Count levels treated -- not injections -- for 64470-64476

Coding for facet injections is fairly easy, as long as you count things correctly--and count the correct part of the procedure. Here are five easy ways to keep your facet injection coding on track.

The lowdown: When coding some injection procedures, you count the number of injections your physician administers. But you code facet injections based on the number of spinal facet joint levels he treats. You should report only a single unit of service for multiple injections at the same spinal level--unless your pain management specialist provides the injections bilaterally. Simply append modifier 50 (Bilateral procedure) for bilateral injections, but be careful to not exceed your carrier's utilization guidelines.

1. Choose 64472, 64476 for Additional Levels

When reporting facet joint injections, you should choose either 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) or 64475 (... lumbar or sacral, single level), depending on the spinal area your physician treats.

For each additional level the physician injects in the cervical or thoracic area, report +64472 (... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]). For each additional level he injects in the lumbar or sacral area, turn instead to +64476 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).

Clarify terminology: Although the descriptors for 64470-64476 specify spinal "levels," your pain management specialist actually targets facet joint injections at the space between vertebrae (in other words, the interspace), not at the vertebrae themselves, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater.

If the specialist documents, for instance, "Facet joint injection at C4-C5," this represents a single injection to the interspace between the fourth and fifth cervical vertebrae, not two separate injections at the fourth and fifth cervical vertebrae.

Example: Your specialist provides facet joint injections at L1-L2 and L2-L3. In this case, you would report 64475 (for the initial lumbar level) and 64476 (for the injection at the additional lumbar level).

2. Same-Level, Same-Side Injections = 1 'Unit'

If the pain management specialist provides more than one injection at the same spinal level and on the same side of the spine, you may report only a single unit of service for most payers, says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C. Example: Your physician must administer two injections to block the medial branch nerves that provide sensory nerve supply to the facet joint. Why: One branch of the nerve sits at the top of the facet joint, and a second branch sits at the bottom.

Some coders mistakenly believe that because the physician must administer two injections, you may bill for two separate injections. This is not the case because the descriptor for 64470-64476 specifically notes "single level," not "per injection."

The three injections for medial branch nerve blocks for C4-C5 and at C5-C6 equal only two levels, although the physician administered a total of three injections (one each at the C4, C5 and C6 medial branches). Therefore, you should report 64470 and 64472.

3. Same Level, Different Side = Bilateral Claim

When the physician provides paravertebral facet joint injections on different sides at the same spinal level, payers will allow you to claim a bilateral procedure (and receive additional compensation) by appending modifier 50 to the appropriate facet joint injection code, Allen says.

For instance, Medicare Part B carrier Noridian Administrative Services LLC specifies that you may report 64470-64476 "with a modifier 50 when injecting a level bilaterally." And the National Physician Fee Schedule Database specifically allows for billing bilateral facet joint injections.

Example 1: Your physician injects intra-articularly or directly into the joint at the right and left C4-C5 and C5-C6 facet joints. You should report 64470-50 (for the initial bilateral injection at C4-C5) and 64472-50 (for the additional bilateral injection at C5-C6).

Example 2: Your physician performs paravertebral facet joint nerve injections at C4, C5 and C6 medial branches on both the right and left sides, for a total of six injections. Again, in this case you would report 64470-50 (for the initial bilateral C4-C5 facet joint level) and 64472-50 (for the additional bilateral C5-C6 facet joint level).

You would not report 64470 and 64472 x 5 because your provider blocked bilateral facet joints at two levels rather than administered six separate facet joint levels.

4. Remember--Utilization Restrictions Matter 
 
When claiming multiple facet joint injections, be aware that many payers restrict the maximum number of code units you may report per session or within a specified time period, Bukauskas-Vollmer says.

Empire Medicare Services, for instance, instructs that claims that exceed six units of 64470-64476 (three bilateral or six unilateral) for the same patient within 180 days "may be subject to review." And Empire's local coverage determination (LCD) says, "Facet joint nerve block injections on more than three spinal levels to a patient on the same day [are] not considered medically necessary."

Another example: Other payers specify similar restrictions. Cahaba GBA's local coverage determination (LCD), effective for dates of service July 1, 2007, and after, states, "The carrier does not expect more than 12 paravertebral facet joint blocks to be performed in a 12-month period per anatomic region (e.g., cervical, thoracic or lumbar). This procedure should be specific in its application and the specific vertebral level being treated should be based on specific documented criteria. Therefore, injection of more than three facet joint levels (unilateral or bilateral) per treatment session, or more frequently than four treatment sessions per anatomic region (e.g., cervical, thoracic or lumbar) over a 12-month period may be reviewed for medical necessity."

5. When Claiming Destruction, Don't Code Block

You should report phenol (or other neurolytic) destruction of the paravertebral facet joint nerve using 64622-64627. Do not confuse these destruction procedures with facet joint injections 64470-64476, which provide only a temporary nerve "block," Allen says.

If the pain management specialist provides facet joint injection (or an anesthetic and/or steroid medication) and nerve destruction at the same location on the same date of service, you should only report the destruction injection.

Good reasons why: CPT's Destruction by Neurolytic Agent section includes the following instructional note: "Codes 64600-64681 include the injection of other therapeutic agents (e.g., corticosteroids)." Likewise, many payer policies include similar statements, such as BCBS of Arkansas, whose LCD states, "If an anesthetic and a neurolytic are both injected at a single or multiple levels, these procedures will be combined and only the neurolytic procedure will be paid."