Neurosurgery Coding Alert

Remember: Don’t report +64492 more than once per day.

When you report paravertebral facet joint injections, you must pay attention to specific details such as which spinal region the surgeon performed the injection and, what type of imaging the surgeon used, and the applicable ICD-10 codes.

Read on to learn more.

Report These 3 Codes for Cervical/Thoracic Injections

When your neurosurgeon performs a cervical or thoracic paravertebral facet joint injection, you should report one (or more) of the following codes, depending upon the encounter’s 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)). You should report 64490 for the first injection the surgeon performs on the cervical or thoracic region of the spine.
• +64491 (... second level (List separately in addition to code for primary procedure)). Report +64491 when the surgeon performs an injection on a second level of the cervical and/or thoracic region during the same encounter.
• + 64492 (... third and any additional level(s) (List separately in addition to code for primary procedure)). Report +64492 when the surgeon performs an injection on the third and any subsequent levels of the cervical and/or thoracic region during the same encounter. You should not report +64492 more than once per day, according to CPT^® guidelines.

Coding example: The medical notes indicate that the surgeon performed injections at two levels of a patient’s cervical region. You should report 64490 and +64491 on the claim.

Turn to These Codes for Lumbar/Sacral Shots

If the surgeon performs a lumbar or sacral facet joint injection, then you should report one (or more) of the following codes, depending upon the encounter’s 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). Note: You should not report + 64495 more than once per day, according to CPT® guidelines.

You should report 64493 for the first injection the surgeon performs on the lumbar or sacral regions of the spine. When the surgeon 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.

Coding example: The surgeon performs an injection at the lumbar level and then a second injection at the sacral level. You should report 64493 and +64494.

“The facet injection codes represent an example of where CPT^® reporting is limited to a maximum number of levels (i.e. three) rather than the number of anatomical levels that could be treated,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “The clinical basis for a maximum reporting of three levels comes from published clinical studies and professional medical association guidelines supporting a maximum of three levels of treatment as medically appropriate.”

Don’t miss: Codes 64490-+ 64495 represent unilateral services, so if the surgeon performs bilateral paravertebral facet injections, you’ll need to append modifier 50 (Bilateral procedure) to the applicable injection code(s).

Count Facet Joint Levels, Not Number of Injections

Coding for paravertebral facet joint injections is based on each facet joint level, not the number of injections. The surgeon might perform multiple injections on the same level.

Example: The surgeon administers facet joint blocks to C3-C4, C4-C5, and C5-C6. You would report the following codes on the claim:

• 64490 for the first level
• +64491 for the second level
• +64492 for the third level and any additional levels in the cervical or thoracic area.

Don’t miss: If the surgeon administers a paravertebral facet joint injection to the T12-L1 joint, or nerves innervating that joint, you should report 64490, according to CPT^® guidelines.

Pay Attention to Type of Imaging

The surgeon must use some type of imaging guidance and localization to perform codes 64490-+64495.

Fluoroscopic and CT guidance and any injection of contrast are included components of 64490-+64495, but ultrasound guidance is not, according to CPT^® guidelines.

Ultrasound guidance: If the surgeon uses ultrasound guidance, then you should report Category III codes for this service. These codes are as follows:

• 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)).

Caution: Keep in mind that commercial payers may consider ultrasound guidance for facet injections as an investigational and/or unproven method for localization and the service may not be a covered benefit, Przybylski says.