Neurology & Pain Management Coding Alert

Remember that intra-articular and medial branch blocks are different.

Administering paravertebral facet joint injections – also known as zygapophyseal joint injections – can be common for your pain management specialist. If you've ever been confused by the terminology and specific types of procedures, read on to get the information you need.

Starting point: Each vertebra has four facet joints, two joints with the vertebra above and two with the vertebra below. Because of the way the vertebrae are aligned, each has two facet joints on the left and two on the right. Common diagnoses associated with paravertebral facet joint injections include:

• M47.1~ – Other spondylosis with myelopathy
• M47.81~ – Spondylosis without myelopathy or radiculopathy
• M47.89~ – Other spondylosis
• M54.2 – Cervicalgia
• M54.5 – Lumbago NOS.

Providers can administer paravertebral facet joint injections for either diagnostic or therapeutic purposes. They can choose between two methods to block the facet joint: an intra-articular joint injection or a medial branch block. This article will take a closer look at intra-articular injections.

Terminology check: When you know what the word "intra-articular" means, you understand exactly what service your provider is offering. "Intra" means "within." "Articular" comes from the word "articulation," which means "joint." Therefore, an intra-articular injection is one that is administered within the joint.

"Your provider might describe the needle placement in his notes with explanations such as, 'directed vertically into the joint space' or 'vertically inserted parallel to the X-ray beam and toward the inferior articular recess,'" says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO,  owner of MJH Consulting in Denver, Co.

Explore Your Code and Modifier Options

CPT^® 2016 includes six codes for paravertebral facet joint injections. As you see, three apply to the level of injection for cervical/thoracic and three apply to lumbar/sacral:

• 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)
• 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).

When looking at the code descriptors, notice that 64492 and 64495 both state, "third and any additional level(s)." As such, you do not report either of these codes more than once per day; once your provider reaches the third level, the code encompasses that injection and any additional ones. CPT^® clarifies this by noting, "Do not report 64492 more than once per day" and, "Do not report 64495 more than once per day."

Modifier 50: The codes represent unilateral services, so you'll need to specify bilateral injections by appending modifier 50 (Bilateral procedure) to the applicable injection code(s).

Modifier 51: The multiple procedure rule associated with modifier 51 (Multiple procedures) applies only to the primary codes (64490 and 64493), but does not apply to the add-on codes (64491, 64492, 64494, and 64495).

For example, consider a claim for intra-articular facet joint injections of T12-L1, L1-L2, and L2-L3. You would report this as 64490, 64493, and 64494. Code 64490 with the highest RVU would be processed at 100 percent of the allowable; 64493 with a slightly lower RVU would be processed with the multiple procedure discount (typically at 50 percent of the allowable); and 64494 would be modifier 51 exempt and processed at 100 percent of the allowable since it is an add-on code.

Count Your Levels Carefully

Coding for paravertebral facet joint injections is based on each facet joint level.

Example: Your physician administers facet joint blocks to C3-C4, C4-C5, and C5-C6. You would code the encounter as 64490 (for the first level), 64491 (for the second level), and 64492 (for the third – and any additional levels in the cervical or thoracic area).

Choosing codes can get confusing if the injection reaches more than one spinal area. If the provider administers a paravertebral facet joint injection to the T12-L1 joint – or nerves innervating that joint – you should report 64490.

Pay Attention to Imaging Tactics

A provider must use some type of imaging guidance and localization to perform the paravertebral facet joint injections represented by codes 64490-64495. Fluoroscopic and CT guidance are included in the code descriptors, but ultrasound guidance is not. CPT^® addresses this in parenthetical notes explaining that you should not report 77002, 77003, or 77012 in conjunction with injection procedures 64490-64495. The Category III code list also states, "Do not report 76942 in conjunction with ... 64490-64495 ... 0213T-0218T."

Solution: If your provider opts for ultrasound guidance with any of these injections, you'll turn to Category III codes to report the service. The structure mirrors those listed above, with the anatomic site and injection level distinguishing the codes:

• 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) (List separately in addition to code for primary procedure)
• 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) (List separately in addition to code for primary procedure).

Editor's note: Next month we'll dig into the specifics of coding for medial branch blocks.