Anesthesia Coding Alert

Hint: Count the number of levels injected, not the number of nerves injected.

Coding and billing for facet joint injections have long been a point of confusion. So much so that Medicare just released an updated local coverage determination (LCD A56670) — developed and adopted by all the Medicare Administrative Contractors (MACs) — to reduce non-compliance and improper payments for these interventions.

Why? According to an audit published in 2021 by the Department of Health and Human Services Office of Inspector General (HHS OIG), one MAC, Noridian, improperly paid $4.2 million to physicians for these services in jurisdiction E during the audit period 2016-2018.

When you report paravertebral facet joint injections, you must do two things to ensure you’re submitting clean claims every time: pay attention to specific details, such as spinal region injected and type of imaging used, and have a good grasp on key concepts like determining the number of units to report. Read on to learn more.

Start With Anatomy and Procedural Basics

The spine is composed of 33 vertebrae divided into five regions: the cervical vertebrae (C1-C7), thoracic vertebrae (T1-T12), and lumbar spine vertebrae (L1-L5), the sacrum, and the coccyx. A facet joint is formed by the articulation between paired bony projections located at the back of each vertebra. Each vertebra has a right and left superior (upper) facet and a right and left inferior (lower) facet, each containing a nerve branch. That’s why physicians must administer two injections to fully block the nerve providing sensory nerve supply to the facet joint.

Providers may perform unilateral or bilateral facet interventions at a specific facet level during the facet joint procedure — a diagnostic nerve block, a therapeutic facet joint (intraarticular) injection, a medial branch block, or the medial branch radiofrequency ablation (neurotomy) — in one session. It’s important to note that a bilateral intervention is still considered a single-level intervention.

Report These 3 Codes for Cervical, Thoracic Injections

When your physician performs a cervical or thoracic facet joint injection, you should report one (or more) of the following codes, depending upon encounter specifics:

• Report 64490 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level) for the first cervical or thoracic injection.
• Report +64491 (... second level (List separately in addition to code for primary procedure)) when the physician injects a second level of the cervical or thoracic spine during the same encounter.
• Report +64492 (... third and any additional level(s) …) for the third and any additional levels injected in the cervical or thoracic regions during the same session. Note, you should not report +64492 more than once per day, according to CPT^® guidelines.

Coding example: The medical notes indicate that the pain management doctor performed injections at two levels of the patient’s cervical spine. You should report 64490 and +64491 on the claim.

Turn to These 3 Codes for Lumbar, Sacral Shots

If the physician performs a lumbar or sacral facet joint injection, then you should report one (or more) of the following codes, depending upon encounter specifics:

• Report 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) for the first lumbar or sacral injection.
• Report +64494 (... second level (List separately in addition to code for primary procedure)) when the provider injects a second level of the lumbar or sacral spine during the same encounter.
• Report + 64495 (... third and any additional level(s) …) for the third and any additional levels injected in the lumbar or sacral regions during the same session. Note, you should not report + 64495 more than once per day, per CPT^® guidelines.

Coding example: The pain management doctor performs a lumbar injection at one level and then a second injection, this time in the sacral region. You should report 64493 and +64494.

“The facet injection codes represent an example of where CPT^® reporting is limited to a maximum number of levels (i.e., three) rather than the number of anatomical levels that could be treated,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “The clinical basis for a maximum reporting of three levels comes from published clinical studies and professional medical association guidelines supporting a maximum of three levels of treatment as medically appropriate.”

Don’t miss: Codes 64490 through +64495 represent unilateral services, so if the physician performs bilateral paravertebral facet injections, you’ll need to append modifier 50 (Bilateral procedure) to the applicable injection code(s).

Turn Your Attention to New Coding Guidance

• Recent revisions to local coverage article A56670, effective for dates of service on and after Jan. 1, 2023, add the following coding guidance for thoracolumbar injections.
• For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and +64494 once.
• For bilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 with modifier 50 and +64494 with modifier 50.

Note: The article goes on to specify, “For CPT^® codes +64492 and +64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.”

Count Facet Joint Levels, Not Number of Injections

Coding for paravertebral facet joint injections is based on each facet joint level, not the number of injections. 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, South Carolina.

Example: The pain management doctor administers facet joint blocks to C3-C4, C4-C5, and C5-C6. You would report the following codes on the claim:

• 64490 for the first level
• +64491 for the second level
• +64492 for the third level (and any additional levels in the cervical or thoracic areas)

Don’t miss: Make sure to append modifier KX (Requirements specified in the medical policy have been met) to the line for all diagnostic injections. In most cases, the KX modifier will only be used for the two initial diagnostic injections.

Pay Attention to Type of Imaging

Fluoroscopic and computerized tomography (CT) guidance and any injection of contrast are included components of 64490 through +64495, but ultrasound guidance is not, according to CPT^® guidelines.

Ultrasound guidance: If the physician uses ultrasound guidance, then you should report Category III codes for this service. These codes are as follows:

• 0213T (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level)
• +0214T (... second level (List separately in addition to code for primary procedure))
• +0215T (... third and any additional level(s) …)
• 0216T (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level)
• +0217T (... second level (List separately in addition to code for primary procedure))
• +0218T (... third and any additional level(s)…)

Caution: Keep in mind that commercial payers may consider ultrasound guidance for facet injections as an investigational and/or unproven method for localization and the service may not be a covered benefit, Przybylski notes.