Neurology & Pain Management Coding Alert

Count each level and check for your payers' preferences.

When reporting facet joint injections, make sure you know the spinal levels that the pain management specialist treated and also what your payers' preferences are for the maximum number and frequency of the injections that can be given. Whether the facet injections are diagnostic or therapeutic, you should count each level and/or both sides. Read on for more advice on reporting these common procedures.

Don't Let Intent Throw You

You'll notice that the terms 'diagnostic' and 'therapeutic' are already in facet joint injection code descriptors, as follows, but don't be too overzealous about those descriptors:

• 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)
• 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).

The reason why the injection was given is not important when billing the procedure. You report the same code irrespective of whether the injection was given for diagnosis or therapy. "From a coding aspect they are both the same codes either way," confirms Marilyn Glidden, CPC, NeuroScience and Spine Associates in Naples, Fla.

Reckon Each Level and Side

The rule of thumb is to count each spinal level the pain management physician treats. You report 64490 when the physician is injecting at the cervical or thoracic level and 64493 when the injection involves the lumbar or sacral level. You do not separately code for multiple injections at the same spinal level. "Code 64490 is reported once for the first level (C3-4), 64491 is reported once for the second level (C4-5) and 64492 is reported once for any additional levels," says Jennifer Schmutz, CPC, health information coder at the Neurosurgical Associates, LLC in Salt Lake City.

Tip: Append modifier 50 (Bilateral procedure) when the injections are given bilaterally. You count two units for bilateral injections at a level. "Some carriers want it 64490-50; others want 2 line items 64490 on the first line 64490-50 on the second," cautions Glidden, so check with your payer to avoid delays and denials. "The key is to check for your payer's preferences," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. "You

do not typically bill bilateral injections as 2 units. You would rather bill them as either the single line item with modifier 50 and 1 unit of service or 2 line items -- 1 line item with modifier RT and 1 unit of service AND 1 line item with modifier LT and 1 unit of service."

For coding purposes, a par vertebral facet (zygapophyseal) joint level is the joint and the two medial nerve branches that originate from two different spinal segments. The injection coding is the same regardless if the physician injected intra-articularly into the facet joint itself or injected the two medial nerve branches. "It is pretty unusual to perform multiple injections on the same site. In contrast, it is quite common for physicians to block the medial branches, i.e. block both sensory nerves that provide innervation to the facet joint," says Hammer.

For an additional level in the cervical or thoracic region, you report +64491 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; second level [List separately in addition to code for primary procedure]) in addition to 64490. For the third level and beyond, you report +64492 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; third and any additional level[s] [List separately in addition to code for primary procedure]) in addition to 64490.

Example: If you read that the pain management specialist performed intra-articular joint injections at T4/T5 and T5/T6 bilaterally, these injections would be reported with 64490-50 and 64491-50. Likewise, if the physician injected the T3, T4 and T5 medial branches bilaterally, the coding would be the same, in that two facet joint levels (T4/T5 and T5/T6) would be blocked.

Avoid Overlap in Block and Destruction

Make sure your physician is doing a facet joint block and not a neurolysis which involves destruction of the nerve. A block is a temporary interruption of the nerve conduction while destruction is a permanent cessation of activity in the nerve when neurolytic agents like heat, radiofrequency techniques, or chemicals are used to destroy the nerve. "The block only numbs the area for a period of time. Neurolysis destroys the nerve & the nerve slowly regenerates," explains Glidden. Codes for destruction are distinct and separate, 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level)-64627 (Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level [List separately in addition to code for primary procedure]).

Confirm Your Payer's Restriction

Many payers describe a number of code units that can be reported for a particular session or the numbers that can be done in a particular period of time. "Most insurers will only cover one injection per level but they can be bilateral," says Glidden.

Example: You read in the operative note that a 45-year-old woman describes lancinating left neck and scalp pain without history of prior trauma, and the CT reveals severe unilateral C2-C3 facet arthropathy for which a fluoroscopically-guided right C2-C3 diagnostic facet injection was given to determine whether or not an inflammatory facet arthropathy is causing occipital neuralgia. In this instance, you would submit 64490 with modifier RT appended as an informational modifier and use diagnosis 721.0 (Cervical spondylosis without myelopathy) or 723.8 (Other syndromes affecting cervical region). "Remember that these codes require image-guidance, which is bundled into each code and not separately reportable. The limited published evidence regarding diagnostic or therapeutic injections of more than three levels prompted the development of CPT® descriptors that bundle all injections beyond the third into the second additional level (64492 for cervicothoracic region and 64495 for lumbosacral region)," says Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.