Pain Management Coding Alert

Question: How would you code a left L5-S1 zygapophyseal (facet) joint aspiration for a facet cyst? Is there a better code than 64999?

Arkansas Subscriber

Answer: CPT® does not include a code for aspiration only of a synovial cyst at a facet joint. Therefore, you should report 64999 (Unlisted procedure, nervous system). If your provider uses fluoroscopic guidance during the procedure, report it with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid], including neurolytic agent destruction). 

Another possibility: Physicians sometimes also inject a local anesthetic or corticosteroid into the facet joint before aspirating the cyst. If so, you would choose the appropriate injection code from 64490-64495 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT …]). You would not report additional codes for the aspiration or fluoroscopy because they will be considered part of the injection procedure.

Filing tip: Be sure to clearly indicate in Box 19 of the 1500 form (or electronic equivalent) what specific service or procedure your provider completed. Your documentation should include any specific information about the procedure, such as an adequate definition or description of the nature, extent, and need for the procedure or service. Notes regarding the time, effort, and equipment necessary to provide the service should also be included.