Orthopedic Coding Alert

Question: We performed several facet joint injections and appended modifier 50 to represent multiple levels, but we only got paid for one level. Can you advise?
Kentucky Subscriber

Answer: If the injections occur on the same side of the spine, you won’t append modifier 50, according to results that recovery audit contractors (RACs) recently provided to CMS, which were published in its Jan. 2015 Medicare Quarterly Provider Compliance Newsletter. The publication focused in on facet joint injections as one procedure that is billed so infrequently that it’s a common source of overpayments. “An overpayment exists when a provider bills for a facet joint injection with an ICD-9 code that is not included on the list of covered ICD-9 codes,” CMS says in the document.

Like you, many practices are confused about when to use a bilateral modifier on facet joint claims vs. using the add-on codes.

The solution: When you report these codes, you should remember to append modifier 50 (Bilateral procedure) only if the physician injects both the right and left sides of the same spinal level, CMS says in its Quarterly Provider Compliance Newsletter.

In addition, facet joint injections on multiple levels on the same side of the spine require you to use the add-on codes, even though many practices simply use modifier 50.

Example: Your physician administers injections to the patient’s L1, L2, L3, L4, and L5 paravertebral facet joint nerves.

Solution: The primary code is 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) reported for the L2-L3 facet joint.
Then add +64494 (…second level [List separately in addition to code for primary procedure]) for the second L3-L4 level injection and +64495 (…third and any additional level[s] [List separately in addition to code for primary procedure]) with only one unit of service for the last two facet joint levels (L4-L5 and L5-S1). It is important to note that the code descriptor for the 64495 add-on code specifies “third and any additional level[s].”

Resource: To read the Jan. 2015 Medicare Quarterly Provider Compliance Newsletter, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909177.pdf.