Facet Joint Injections CPT 64490 - 64493 - 64495 - DX 721.0 - 738.4 - Fee amount

Procedure code and Description

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

64490 - Replaces 64470 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 - average fee payment - $200 - $210

64491 - Inj paravert f jnt c/t 2 lev - average fee payment - $90 - $110


64492 - Inj paravert f jnt c/t 3 lev - average fee payment - $90 - $110

Coverage Indications, Limitations, and/or Medical Necessity

    Facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are

        The pain does not have a strong radicular component.

        There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.


    A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g.. C4-5 or L2-3). It is further noted that there are two (2) facet joints at each level, left and right.

Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are as follows:

  • The pain does not have a strong radicular component.
  • There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. For purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level by the vertebrae that form it (e.g., C4-5 or L2-3). It is further noted that there are two (2) facet joints at each level, left and right.

During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future. Some patients will have long-lasting relief with local anesthetic and steroid; others will require a denervation procedure for more permanent relief. Before proceeding to a denervation treatment, the patient should experience at least a 50 percent reduction in symptoms for the duration of the local anesthetic effect.

Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fails to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495).

Limitations

Medicare does not expect that an epidural block or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage will be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management.

Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by CPT codes 64490–64495. For paravertebral spinal nerves and branches – image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of CPT codes 64490–64495.

The CPT codes included in this policy include CT or fluoroscopic guidance; do not bill these codes unless CT or fluoroscopic guidance is performed. If guidance is performed with Magnetic Resonance Imaging (MRI) or if no guidance is performed, use an appropriate unlisted CPT/HCPCS code such as 64999. If the service is performed with ultrasound guidance, bill with the appropriate HCPCS code(s) from the 0213T–0218T series of codes.

The CMS Internet-Only Manual (IOM) Pub.100-08, Program Integrity Manual, Chapter 13, Section 5.1, outlines that “reasonable and necessary” services are “ordered and /or furnished by qualified personnel.” Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. Training and expertise must have been acquired within the framework of an Accreditation Council for Graduate Medical Education(ACGME) accredited residency and/or fellowship program in the applicable specialty/subspecialty. If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit. Documentation of training must be available upon request.

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
64490©
Inj paravert f jnt c/t 1 lev - Fee schedule amount $191.28
64491© 
Inj paravert f jnt c/t 2 lev  Fee schedule amount $ 95.05
64492©
Inj paravert f jnt c/t 3 lev  Fee schedule amount $ 95.39
64493©
Inj paravert f jnt l/s 1 lev  Fee schedule amount $ 173.41
64494©
Inj paravert f jnt l/s 2 lev  Fee schedule amount $ 87.48
64495©
Inj paravert f jnt l/s 3 lev  Fee schedule amount $ 87.82 

Billing and Coding Guidelines CPT CODE 64493, 64495, 64490


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

1. Each CPT code listed (single level, second level, third and any additional levels) may be billed with a Modifier 50 when injecting a level bilaterally. For one level unilateral or bilateral CPT codes 64490 or 64493 should be used. If the facet joint injection is performed at more than one level unilateral or bilateral CPT codes 64491, 64492, 64494 or 64495 should be used for the additional levels. For bilateral procedures Modifier 50 should be appended to the procedure codes with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 claim form (or electronic equivalent) and link it to the applicable ICD-9-CM code listed above under the ICD-9-CM Codes that Support Medical Necessity section.

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64490- 64495.

4. If the injection is made around or into the spinal nerve, the service should be billed as a paravertebral nerve injection.

5 When destruction of the facet joint nerve is performed following the blockage, only the codes for the nerve destruction should be billed since their allowance includes that of the facet nerve blockage procedure

Paravertebral Facet Joint Denervation

1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636. 

Summary of Direct Crosswalk Codes Decision Regarding Facet Joint Injection:

There were four codes (64470, 64472, 64475, and 64476) active prior to January 1, 2010 for facet joint injection. All four codes expired as of December 31, 2009. Six new replacement codes (64490-64495) were created effective January 1, 2010 to replace the four facet joint injection codes listed above. Instead of one code for any additional level after the first level, CPT broke out the secondary level and the third and any additional level into two separate codes. Due to the unique nature of this situation, UnitedHealthcare intends to:

** Crosswalk the contracted fee from 64470 to 64490
** Crosswalk the contracted fee from 64472 to 64491 and 64492
** Crosswalk the contracted fee from 64475 to 64493
** Crosswalk the contracted fee from 64476 to 64494 and 64495

Facet/Medial Branch Block Injections:

** Therapeutic Facet/Medial Branch Block Injections are not covered.

** Diagnostic Facet/Medial Branch Block Injections will have a limit of four per calendar year applied to CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.

** Facet/Medial Branch Block Injections must be performed by a physician/practitioner as required by T.C.A 63-7-126 (attached).


** Medical records are required when submitting a claim with CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.


For claims with dates of service on or after Oct. 1, 2013, UnitedHealthcare Community Plan will make changes to the following member benefits:

* Facet/Medial Branch Block Injections

* Trigger Point Injections

* Epidural Steroid Injections

* Urine Drug Screens

* TENS Unit for Chronic Lower Back Pain (CLBP)

Facet/Medial Branch Block Injections:

* Therapeutic Facet/Medial Branch Block Injections are not covered.

* Diagnostic Facet/Medial Branch Block Injections will have a limit of four per calendar year applied to CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.

* Facet/Medial Branch Block Injections must be performed by a physician/practitioner as required by T.C.A 63-7-126  attached).

* Medical records are required when submitting a claim with CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.

The Reporting of Bilateral Procedures Using Modifier -50

Modifier - 50 is used by providers and suppliers, other than ambulatory surgical centers (ASCs), to report bilateral procedures when the term “bilateral” is not included in the code descriptor of a CPT® code. Because this modifier is used when specific pain medicine procedures are performed bilaterally, this topic will be of particular interest to ASA members practice pain medicine. The intent of this modifier is to report an appropriate unilateral procedure when performed bilaterally, and there is no bilateral CPT code to report what has been done. The Centers for Medicare and Medicaid Services (CMS) defines a bilateral service as one in which the same procedure is performed on both sides of the body during the same operative session or on the same day. These bilateral procedures are performed either on the same operative area (e.g. breast, nose, eyes) or in separate operative areas (e.g. feet, arms, legs).

In the past, Medicare allowed bilateral procedures when the term “bilateral” was not included in the code descriptor, to be reported by different methods that were correct only in certain circumstances. For example, CPT notes that facet joint injections as described by codes 64490 - 64495 are unilateral procedures; modifier 50 is to be appended when the procedure is done bilaterally, Common methods to report the scenario in which the injection was done bilaterally at one single lumbar level were:

* two units of service (UOS) reported on a single line with no modifier

Example:

64493, Units=2

* one UOS on each of the separate lines using the modifiers RT and LT;

* Example:

64493–RT, Units = 1

64493–LT, Units = 1

* one UOS on one line using the modifier -50

Example:

64493-50, Units=1

Recently, CMS implemented a Medically Unlikely Edit (MUE) that will render the reporting of bilateral procedures where the term “bilateral” is not included in the CPT code descriptor, as unpayable when reported on two claim lines using the RT and LT modifiers or by reporting two units of service on a single line with no modifier. The National Correct Coding Initiative (NCCI) and the Medicare Claims Processing Manual now require the practitioner or suppler to report these procedures using a single unit of service on a single claim line using the -50 modifier – per the third bullet point above


ICD-10 Codes that Support Medical Necessity

    
    M25.50 Pain in unspecified joint

    M47.14 Other spondylosis with myelopathy, thoracic region

    M47.15 Other spondylosis with myelopathy, thoracolumbar region

    M47.16 Other spondylosis with myelopathy, lumbar region

    M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region

    M47.22 Other spondylosis with radiculopathy, cervical region

    M47.23 Other spondylosis with radiculopathy, cervicothoracic region

    M47.24 Other spondylosis with radiculopathy, thoracic region

    M47.25 Other spondylosis with radiculopathy, thoracolumbar region

    M47.26 Other spondylosis with radiculopathy, lumbar region

    M47.27 Other spondylosis with radiculopathy, lumbosacral region

    M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region

    M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

    M47.812 Spondylosis without myelopathy or radiculopathy, cervical region

    M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region

    M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region

    M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region

    M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

    M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

    M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

    M47.891 Other spondylosis, occipito-atlanto-axial region

    M47.892 Other spondylosis, cervical region

    M47.893 Other spondylosis, cervicothoracic region
    M47.894 Other spondylosis, thoracic region

    M47.895 Other spondylosis, thoracolumbar region

    M47.896 Other spondylosis, lumbar region

    M47.897 Other spondylosis, lumbosacral region

    M47.898 Other spondylosis, sacral and sacrococcygeal region
    M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region

    M54.04 Panniculitis affecting regions of neck and back, thoracic region

    M54.05 Panniculitis affecting regions of neck and back, thoracolumbar region

    M54.06 Panniculitis affecting regions of neck and back, lumbar region

    M54.07 Panniculitis affecting regions of neck and back, lumbosacral region
    M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region

    M54.09 Panniculitis affecting regions, neck and back, multiple sites in spine

    M54.2 Cervicalgia

    M54.5 Low back pain

    M54.6 Pain in thoracic spine

    M62.830 Muscle spasm of back

    M96.1 Postlaminectomy syndrome, not elsewhere classified



    Z79.01* Long term (current) use of anticoagulants


ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64490, 64491, 64492, 64493, 64494 and 64495:

Covered for:
721.0–721.3
Cervical spondylosis without myelopathy
721.41–721.42
Spondylosis with myelopathy lumbar region
721.90
Spondylosis of unspecified site without mention of myelopathy
722.10–722.11
Displacement of thoracic or lumbar intervertebral disc without myelopathy
722.4
Degeneration of cervical intervertebral disc
722.51–722.52
Degeneration of thoracic or lumbar intervertebral disc
722.71–722.73
Intervertebral disc disorder with myelopathy
722.81–722.83
Postlaminectomy syndrome (cervical, thoracic, lumbar region)
723.1
Cervicalgia
724.00–724.03
Spinal stenosis, other than cervical
724.1
Pain in thoracic spine
724.2
Lumbago
733.13
Pathologic fracture of vertebrae
738.4
Acquired spondylolisthesis
805.00–805.08
Cervical fracture, closed
805.2
Dorsal (thoracic) fracture, closed
805.4
Lumbar fracture, closed
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • Preprocedural evaluation leading to suspicion of the presence of facet joint pathology must be explicitly documented in the patient’s medical record along with postprocedural conclusions.

Diagnostic Phase
  • Procedures performed will be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD.
  • A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect).
  • Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

Therapeutic Phase
  • Medicare will not cover/provide payment for CPT codes 64490 and 64493 (with or without the 50 modifier) more than five (5) times in a year. This practice is never medically reasonable or necessary.
  • Procedures performed will be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD.
  • Medicare does not expect patients to routinely undergo repeat treatment at the same anatomic region at less than 90-day intervals.
  • Medicare does not expect all patients in a provider's practice to present with pain in both anatomical regions (cervicothoracic and lumbosacral). Therefore the routine performance of facet joint/medial branch block (both diagnostic and therapeutic) to both regions may prompt a pre-payment review.
  • Routinely exceeding the above parameters, by utilizing the procedure codes on the same beneficiary in unusual patterns may result in pre-payment review.
  • Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. The medical record must clearly support both procedures. Medicare recognizes that this is not common and will monitor the frequency with which these codes are combined. Multiple procedure modifiers will apply to intraarticular sacroiliac injection.

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