Orthopedic Coding Alert

Hint: You may be reporting too many units of 64470-64476

When billing facet joint injections (64470-64476), do you report multiple units of service for multiple injections at the same spinal level? Unless the surgeon performs bilateral injections, you are probably overbilling the physician's service .

Check out the top five facet joint injection questions that readers submitted to us, along with expert recommendations on how to report the procedures.

Does 1 Level Equal 1 Code?
 
Question 1. Our orthopedic surgeon administered two injections to block the medial branch nerve inside the joint at T1/T2 because one nerve branch sits at the top of the facet joint and a second branch sits at the bottom. Which codes should we report?

Answer: You should report one unit of 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) and call it a day.

If the surgeon administers more than one injection at the same spinal level and on the same side of the spine, you should report only a single unit of service to most payers, says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

The descriptor for 64470 specifically notes "single level" and not "per injection," so you should never report two units of 64470 for several injections to one side of a spinal level.

Remember: Although the facet joint injection descriptors specify spinal "levels," the surgeon actually targets facet joint injections at the space between vertebrae, not at the vertebrae themselves, says Susan Allen, CPC, CCS-P, coding manager and compliance officer for Florida Spine Institute in Clearwater, Fla.

If the surgeon documents, for instance, "Facet joint injection at C4/C5," this represents a single injection to the space between the fourth and fifth cervical vertebrae, not two separate injections at the fourth and the fifth vertebrae.

Another example: Suppose the surgeon performs two unilateral facet joint injections at T1/T2 and two more at T2/T3. You should report one unit of 64470 and one unit of +64472 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level [list separately in addition to code for primary procedure]).

Can We Report Fluoro With Facet Joint Injection?

Question 2: Our surgeons normally use fluoroscopic guidance to place the needle for facet joint injections. Can we bill separately for the fluoroscopy?

Answer: Yes. You should report a single unit of 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction), regardless of how many injections the orthopedist administers under fluoroscopic guidance. Most insurers will deny additional units of 76005 in this circumstance.

For example, Noridian Administrative Services LLC, a Medicare Part B carrier in several states, reminds coders in its guidelines that the descriptor for 76005 specifies that the code is for injection procedures (plural), so you may only bill the code "once regardless of the number of levels addressed."

You usually won't need to append modifier -51 (Multiple procedures) when you report 76005, but you should append modifier -26 (Professional component) if the surgeon:

1. interprets only the fluoroscopy results,

2. performs the procedure in a hospital facility, or

3. uses equipment that she does not own.

Does Modifier -50 Apply?

Question 3: Our surgeon administered three bilateral facet joint injections into the lumbar spine area. Which codes should we report?

Answer: The answer depends on whether the surgeon performed three bilateral injections to one lumbar level or whether he addressed two or three levels.

Assuming he injected three separate lumbar levels, you should report 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) once with modifier  -50 (Bilateral procedure) attached, followed by two units of +64476 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).

Most insurers' policies dictate that modifier -50 applies to facet joint injections, and the National Physician Fee Schedule Database specifically allows you to bill these codes bilaterally.

If the surgeon only treated one spinal level bilaterally, you should report 64475-50 just once.
 
Why Would Our Carrier Deny Injections?

Question 4: One of our patients required facet joint injections at four levels, and our insurer paid us for the service. The patient returned to our practice five months later and we injected the same four levels, but the insurer denied the claim, saying that we had exceeded frequency guidelines. What type of frequency guidelines did we violate?

Answer: Many insurers restrict the maximum number of code units you can report per session, or within a specified time period, Bukauskas-Vollmer says.

Empire Medicare Services, a Part B carrier in New York and New Jersey, for instance, instructs that claims in excess of six units of 64470-64476 (three bilateral or six unilateral) for the same patient within a 180-day period "may be subject to review."

In addition, Empire's policy states, "Facet joint nerve block injections on more than three spinal levels to a patient on the same day are not considered medically necessary."

Therefore, even though your payer was more liberal than Empire when they paid you for three levels during one visit, your payer probably publishes similar guidelines limiting you to six units within a 180-day period - and you billed eight units within 150 days.

Other payers publish similar guidelines. Noridian's policy, for instance, says, "Given that a facet joint receives nerves from three levels, it is appropriate to block three levels when one level of facet joint involvement is suspected." Although the statement doesn't specifically limit physicians to three units of 64470-64476 per session, Noridian implies that claims in excess of three code units per session may be unsupported.

Is Destruction a Block?

Question 5: Our surgeon documented lumbar paravertebral facet joint nerve destruction and circled 64475, but our coding staff thinks that we should report 64622 instead. Who is correct?

Answer: Your coding staff is correct. If your surgeon performs phenol or other neurolytic destruction of the paravertebral facet joint nerve, you should report 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) or the site-appropriate code from the 64623-64627 series.

Do not confuse destruction procedures with facet joint injections 64470-64476, which provide only a temporary nerve "block," Allen says.

And if the surgeon performs a facet joint injection and nerve destruction at the same location on the same date of service, you should report the destruction injection code only.

And Medicare policy specifically states, "When destruction of the facet joint nerve is performed following the blockade," you should report "only the codes for nerve destruction."