Orthopedic Coding Alert

Remember: Cervical/thoracic, lumbar/sacral shots might be multi-code encounters.

Patients reporting to the orthopedist for paravertebral facet joint injections pose a specific set of problems for coders who want to submit spotless claims.

First, you've got to get the injection levels right in order to gain maximum deserved reimbursement. Further, you'll need to check with your insurer to see if it requires proof that you tried more conservative therapies before opting for a facet joint injection.

Take a look at this expert advice on these injections to make sure your coding is on point every time.

Use this Code Trio for Cervical/Thoracic Injections

When a patient reports to the orthopedist for a cervical or thoracic paravertebral facet joint injection, you'll report one (or more) of the following codes, depending on encounter 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)
• +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).

Remember that these codes are per level, not per injection; the orthopedist might perform multiple injections on the same level. When she performs injections at another cervical/thoracic level, then you'll choose an add-on code to represent injections to additional levels.

Often, patients will need these injections for "chronic, persistent pain suspected to originate from the facet joint," explains Denise Caposella, CPC, senior consultant at Acevedo Consulting Incorporated in Delray Beach, Florida.

Here's a breakdown of the three codes and how you should use them:

• Report 64490 for the first injection the orthopedist performs on the cervical or thoracic region of the spine.
• Report +64491 when the orthopedist performs an injection on a second level of the cervical and/or thoracic region during the same encounter.
• Report +64492 when the orthopedist performs an injection on the third and any subsequent levels of the cervical and/or thoracic region during the same encounter.

So, let's say that notes indicate that the orthopedist performed injections at two levels of a patient's cervical region; on the claim, you'd report 64490 and +64491.

Rely on these Codes for Lumbar/Sacral Shots

When a patient reports to the orthopedist for a lumbar or sacral facet joint injection, you'll report one (or more) of the following codes, depending on encounter 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).

Report 64493 for the first injection the orthopedist performs on the lumbar or sacral regions of the spine, Caposella explains. When the provider 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.

Remember that these codes are per level, not per injection; the orthopedist might perform multiple injections on the same level. When she performs injections at another lumbar/sacral level, then you'll choose an add-on code to represent injections to additional levels.

For example, if the orthopedist performs an injection at the lumbar level and then a second injection at the sacral level, you'd report 64493 and +64494, explains Caposella.

Payer Preference Drives Previous Tx Decision

Before considering paravertebral facet joint injections of any type, the practice might need to have evidence that it tried more conservative types of therapy before the injections, Caposella warns. So, make sure you check payer guidelines to see if the patient is eligible for these injections.

"Individual payers may have specific requirements as to whether or not conservative treatments are required prior to administering paravertebral injections," Caposella explains.

If the payer does require proof of more conservative therapies before signing off on paravertebral injections, some of the therapies might include:

• inactive components such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (including trigger point), and diathermy.
• active modalities such as physical therapy, a physician supervised home exercise program, and/or chiropractic care.