Neurology & Pain Management Coding Alert

Here's how these encounters might involve multiple codes.

Coders in the know are well aware that each time a patient reports to the PM specialist for paravertebral facet joint injections, they've got to be on their toes.

Why? They know that in order to maximize rightful reimbursement, they need to get the injection levels right. There might also be payer issues, as policies vary on the question of pre-injection conservative therapies.

Get the lowdown on these injections to make sure your coding is on point every time.

Use these 3 Codes for Cervical/Thoracic Shots

When a patient reports to the PM specialist for a cervical or thoracic paravertebral facet joint injection, you'll report one (or more) of the following codes, depending on encounter specifics:

• 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)
• +64491 - ... second level (List separately in addition to code for primary procedure)  
• + 64492 - ... third and any additional level(s) (List separately in addition to code for primary procedure).

Remember that these codes are per level, not per injection; the PM specialist might perform multiple injections on the same level. When she performs injections at another cervical/thoracic level, then you'll choose an add-on code to represent injections to additional levels.

Often, patients will need these injections for "chronic, persistent pain suspected to originate from the facet joint," explains Denise Caposella, CPC, senior consultant at Acevedo Consulting Incorporated in Delray Beach, Florida.

Here's a breakdown of the three codes and how you should use them:

• Report 64490 for the first injection the PM specialist performs on the cervical or thoracic region of the spine.
• Report +64491 when the PM specialist performs an injection on a second level of the cervical and/or thoracic region during the same encounter.
• Report +64492 when the PM specialist performs an injection on the third and any subsequent levels of the cervical and/or thoracic region during the same encounter.

So, let's say that notes indicate that the PM specialist performed injections at two levels of a patient's cervical region; on the claim, you'd report 64490 and +64491.

Use these Codes for Lumbar/Sacral Injections

When a patient reports to the PM specialist for a lumbar or sacral facet joint injection, you'll report one (or more) of the following codes, depending on encounter specifics:

• 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
• +64494 - ... second level (List separately in addition to code for primary procedure)
• + 64495 - ... third and any additional level(s) (List separately in addition to code for primary procedure).

Report 64493 for the first injection the PM specialist performs on the lumbar or sacral regions of the spine, Caposella explains. When the provider also performs injection(s) on a second level of the lumbar and/or sacral region during the same encounter, report +64494. For the third or any subsequent levels of injection during the same encounter, report +64495.

Remember that these codes are per level, not per injection; the PM specialist might perform multiple injections on the same level. When she performs injections at another lumbar/sacral level, then you'll choose an add-on code to represent injections to additional levels.

For example, if the PM specialist performs an injection at the lumbar level and then a second injection at the sacral level, you'd report 64493 and +64494, explains Caposella.

Payer Preference Will Determine Previous Tx Decision

Before considering paravertebral facet joint injections of any type, the PM clinic might need to have evidence that it tried more conservative types of therapy before the injections, Caposella warns. So, make sure you check payer guidelines to see if the patient is eligible for these injections.

"Individual payers may have specific requirements as to whether or not conservative treatments are required prior to administering paravertebral injections," Caposella explains.

If the payer does require proof of more conservative therapies before signing off on paravertebral injections, some of the therapies might include:

• inactive components such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (including trigger point), and diathermy.
• active modalities such as physical therapy, a physician supervised home exercise program, and/or chiropractic care.