Neurology & Pain Management Coding Alert

Count levels treated, not injections, for 64470-64476

For facet joint injections (64470-64476), you should report only a single unit of service for multiple injections at the same spinal level - unless the neurologist provides the injections bilaterally.

For bilateral injections, you may append modifier -50 (Bilateral procedure), but you must be careful not to exceed payer 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 area of the spine level the neurologist treats.
 
For each additional level the neurologist 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 the neurologist 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]).
 
Although the descriptors for 64470-64476 specify spinal "levels," the neurologist 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, Fla. If the neurologist documents, for instance, "Facet joint injection at C4/C5," this represents a single injection to the interspace between the forth and fifth cervical vertebrae, not two separate injections at the fourth and fifth cervical vertebrae.

Example: The neurologist 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 an additional lumbar level).

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

If the neurologist provides more than one injection at the same spinal level, and on the same side of the spine, you may only report a single unit of service for most payers, says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

Example: The neurologist must administer two injections to block the median branch nerve inside the joint because 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 neurologist must administer two injections, they may bill for two separate injections. This is not the case: The descriptor for 64470-64476 specifically notes "single level," not "per injection."
 
Two injections for a nerve block at T1/T2 and two more at T2/T3 equals only two levels, although the physician administered a total of four injections. Therefore, you should report 64470, 64472.

3. Same Level, Different Side = Bilateral Claim

When the neurologist provides multiple injections on different sides of the spine at the same 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 of bilateral facet joint injections.

Example: The neurologist injects the left and right side at T6/T7 and T7/T8. You should report 64470-50 (for the initial bilateral injection at T6/T7) and 64472-50 (for the additional bilateral injection at T7/T8).

Example 2: The neurologist provides two injections to the right side at T6/T7 and injections on both the right and left side at T7/T8

In this case, you should report the bilateral injection at T7/T8 with 64470-50, and 64472 for the additional injections at T6/T7 (remember, multiple injections on the same side count as a single unit).

4. 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 in excess of 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 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."

Other payers specify similar restrictions. Noridian's policy, for instance, says, "Given that a facet joint receives nerves from three levels, it is appropriate to block three levels when one level of facet joint involvement is suspected." Although this statement doesn't specifically limit providers to three units of 64470-64476 per session, Noridian implies that claims in excess of three code units per session are unsupported.

5. When Claiming Destruction, Don't Code Block

You should report phenol (or other neurolytic) destruction of the paravertebral facet joint nerve using codes 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 neurologist should provide facet joint injection and nerve destruction at the same location on the same date of service, you should report the destruction injection only. Medicare policy specifically states, "When destruction of the facet joint nerve is performed following the blockade [64470-64476]," you should report "only the codes for nerve destruction."