Neurology & Pain Management Coding Alert

If your practice is like many neurology offices incorrectly reporting facet joint injections, now's the time to fix your errors -- or you could be facing major payback requests.

Heads up: 63 percent of facet joint injections allowed in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments for physician services, according to a September 2008 OIG report. Associated facility claims had an additional $33 million in improper payments.

Lumbar facet joint nerve neurolytic destruction indications for many payers include intervertebral lumbar disk disorder or degeneration with or without myelopathy, lumbar spondylosis with or without myelopathy, nerve root disorders, lumbar postlaminectomy syndrome, spinal stenosis, lumbago, and congenital anomaly of the spine, said Linda Van Horn, MBA, at a conference of the Society for Pain Practice Management in Phoenix in March.

For the indications above, you will use:

• 64622 -- Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level

• +64623 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure).

Tip: For facet joint nerve destruction, coding is based on each nerve treated.

Example: Report the destruction of L4 and L5 facet joint nerves as two levels. Use codes 64622 and one unit of +64623. Payers vary in the maximum number of nerve destruction allowed on one date of service and diagnosis that meet medical necessity. Check the individual payer policy for coverage.

Anesthetic agent and/or steroid facet joint/facet joint nerve injections are billed differently than neurolytic facet joint nerve destructions. Trying to bill them the same way will earn you much higher compliance risk and potentially a payer review.

Bill facet joint/facet joint nerve injections of an anesthetic and/or steroid per facet joint level. The codes for the diagnostic/therapeutic facet joint injections differ when it comes to distinguishing between the cervical/thoracic and lumbar/sacral spinal regions:

• 64470 -- Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

• +64472 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

• 64475 -- ... lumbar or sacral, single level

• +64476 -- ... lumbar or sacral, each additional level(List separately in addition to code for primary procedure).

Neurolytic destruction procedures, on the other hand, are billed per nerve. Again, the different facet joint nerve destruction codes are based on the spinal region:

• 64622 -- Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level

• 64623 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

• 64626 -- ... cervical or thoracic, single level

• +64627 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure).

Intra-articular facet joint injections are commonly documented at facet joint level -- for example, a right L4-L5 facet joint injection or a left C6-C7 intra-articular facet injection. Facet joint nerve injections (a.k.a. medial branch blocks) are often documented per nerve, such as right L3 and L4 medial branch blocks, or left C6 and C7 facet joint nerve injections.

Each facet joint level -- for instance, C6-C7 -- has sensory innervation from two facet joint nerves, such as the C6 and C7 medial branches. Compliant coding requires facet joint injections be based on facet joint level, not per each individual nerve injected.

Put another way, "If you do one interspace on one side you have done one procedure," clarifies Scott Groudine, MD, professor of anesthesiology and surgery at Albany Medical Center, in New York.

"If you do right and left at the same interspace you have done two procedures and should apply the appropriate modifier" -- 50 (Bilateral procedure), RT (Right side), or LT (Left side).

Example 1: A C6-C7 intra-articular facet joint injection = 1 injection code (64470).

Example 2: Injections of both the C6 and C7 facet joint nerves (two needle placements and two injections) = 1 level (C6-C7) = 1 injection code (64470).

Compliant coding of facet joint nerve destruction procedures, however, are reported based on each individual nerve, rather than the facet joint level. Hence, report radio frequency destruction of both the C6 and C7 facet joint nerves with two codes: 64626 and 64627.

Watch for Bilateral Facet Codes

Lumbar facet joint and facet joint nerve procedures are unilateral. You can bill these procedures bilaterally. Use modifier 50, says Van Horn, who is CEO of 21st Century Edge, a pain management practice management consulting firm in Kansas City, Mo.

Careful: Some payers require modifiers RT and LT, rather than modifier 50. Bilateral lumbar facet procedures reimburse at 150 percent of the base reimbursement, Van Horn adds.