Wiki billing bilateral for 64493 and 64494

[delatorreyadira@gmail.com]

Good afternoon,

Hello everyone, can someone please explain to me if I am understanding the coding correctly, I am currently helping a Pain Management provider with his billing and coding, with what I had read for the paravertebral facet joint injections at two levels bilaterally (e.g., L1-L2 and L2-L3), we code 64493 with Modifier 50 and 64494, 64494. I have appended modifier 59 on the second 64494 because it was the only code getting denied. I need advice if I am missing a step in how these codes should be billed for?

 

[CBLENNIE]

If you are billing 64494 for a total of 2 units for the DOS, you are probably being denied the 2nd unit due to the MUE allowance for the procedure being 1 unit per DOS.


The MUE MAI indicator for 64494 is 2, which is an absolute DOS edit based on policy. CMS Manual Pub 100-20 One-Time Notification includes processing instructions and a detailed explanation of MAI 2 & 3. Here is are snips of part of the explanation of MAI 2.




The bottom line is only 1 unit of 64494 is going to be allowed per DOS per provider.

 

[delatorreyadira@gmail.com]

If you are billing 64494 for a total of 2 units for the DOS, you are probably being denied the 2nd unit due to the MUE allowance for the procedure being 1 unit per DOS.
View attachment 7179

The MUE MAI indicator for 64494 is 2, which is an absolute DOS edit based on policy. CMS Manual Pub 100-20 One-Time Notification includes processing instructions and a detailed explanation of MAI 2 & 3. Here is are snips of part of the explanation of MAI 2.

View attachment 7177
View attachment 7178

The bottom line is only 1 unit of 64494 is going to be allowed per DOS per provider.

Yes that’s my understanding but is it okay to add modifier 59 on the second line item for cpt code 64494 ?

 

[amyjph]

You would bill it on two lines only with modifier 50 on each. You are trying to report three total lines. Modifier 59 does not come into play. If it is L1-2, L2-3 bilateral for example, it is:
L1-2 bilateral: 64493-50 one unit one line
L2-3 bilateral: 64494-50 one unit one line

Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.

FYI: (8/1/24): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35936
(ends 7/31/24): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35936&ver=43&

1. One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations that are performed during the same day.

There could be some payers that have a weird policy on this but above is CMS way.

 

[delatorreyadira@gmail.com]

You would bill it on two lines only with modifier 50 on each. You are trying to report three total lines. Modifier 59 does not come into play. If it is L1-2, L2-3 bilateral for example, it is:
L1-2 bilateral: 64493-50 one unit one line
L2-3 bilateral: 64494-50 one unit one line

Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.

FYI: (8/1/24): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35936
(ends 7/31/24): https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35936&ver=43&

1. One to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., medial branch block (MBB), intraarticular injections (IA), facet cyst ruptures, and RFA ablations that are performed during the same day.

There could be some payers that have a weird policy on this but above is CMS way.

thank you I appreciate your help.

 

[ambernic]

Good afternoon,

Hello everyone, can someone please explain to me if I am understanding the coding correctly, I am currently helping a Pain Management provider with his billing and coding, with what I had read for the paravertebral facet joint injections at two levels bilaterally (e.g., L1-L2 and L2-L3), we code 64493 with Modifier 50 and 64494, 64494. I have appended modifier 59 on the second 64494 because it was the only code getting denied. I need advice if I am missing a step in how these codes should be billed for?

Per CPT guidelines it states, "Report add-on codes 64491, 64492, 64494, and 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495." I don't think modifier 59 is necessary. I believe you are billing correctly. I would appeal this based on the CPT guideline.

 

[amyjph]

Per CPT guidelines it states, "Report add-on codes 64491, 64492, 64494, and 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495." I don't think modifier 59 is necessary. I believe you are billing correctly. I would appeal this based on the CPT guideline.

I respect what you are saying and CPT does say that however, if the payer is CMS or the payer follows CMS or has their own policy it won't matter what CPT says and appeal won't work.