Question: The provider has performed facet joint aspiration for a facet cyst at right L5-S1.
Please suggest the appropriate code.
Arkansas Subscriber
Answer: Since a specific code for facet joint cyst aspiration is unavailable in CPT®, you will have to report 64999 (Unlisted procedure, nervous system). If the provider used fluoroscopic guidance in the procedure, additionally report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]).
If the provider injected a local anesthetic or corticosteroid into the facet joint before aspirating the cyst choose the appropriate injection code from 64490-64495 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT]). You would not need to additionally report codes for aspiration or fluoroscopy as they will be included in the injection procedure.