Facet Joint Injection

The qualified healthcare providers injects a diagnostic or therapeutic agent into a facet joints to treat the spinal pain or to identify the exact source of pain with using of imaging guidance of either fluoroscopy or CT scan. 

The joints are connecting into two spinal vertebrae together as following, 

• Cervical Level
• Thoracic Level. 

All of the spine, at each level, a pair of small facet joints connects the vertebrae, the bony building blocks of the spine holding the vertebral column together and providing support. 

These small joints may become inflamed due to a variety of conditions including osteoarthritis, disc degeneration, spinal stenosis, or from trauma such as a car accident.

When the facet joints become swollen and enlarged because of injury or arthritis, it causes pain, 

• If the affected joint is in the neck, it may cause headaches and difficulty moving the head. 
• If it is in the back, it may cause pain in the lower back, buttocks, or legs.

In cases where conservative approaches, such as anti-inflammatory medications, chiropractic manipulation, and physical therapy, don’t provide sufficient relief, denervation or injection into or around the facet joint may help relief the pain

For this service, the provider preps and anesthetizes the patient for a facet joint injection. The provider then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis.

• Computed tomography, or CT, is when the provider rotates an X–ray tube and X–ray detectors around a patient, which produces a tomogram, a computer generated cross sectional image; providers use CT to diagnose, manage, and treat diseases.
• Fluoroscopy is a live X–ray where the X–ray image appears on a fluorescent screen television monitor; providers often use fluoroscopy to view body structures while performing procedures.

Do not separately code for multiple injections at the same spinal level and do not bill imaging guidance, specifically fluoroscopy or CT.

A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. The facet joint is noted at a specific level by the vertebrae that form it (e.g., C4-5 or L2-3). There are two facet joints at each level, left and right, and there are 28 levels of facet joints.

Each facet joint is supplied by the medial branches of two different spinal nerves. Two to three medial branch nerves innervate each lumbar facet joint, and two nerves innervate each cervical and thoracic facet joint. These nerves are branches of the posterior division of the spinal nerves, located immediately above and below the joint.

For example, innervation of the facet joints at L4-L5 is supplied by medial branches originating from the L3 and L4 spinal nerves. As such, the physician must block two median nerves for each facet joint. In the case of a medial branch nerve block at L4-L5, the physician would inject the medial branches of L3 and L4. For coding purposes, these two injections are considered a single injection service.

CPT Codes

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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

+64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

+64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

+64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

+64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Tips

• Codes 64490-64495 are unilateral procedures.
• Use CPT codes 64490 and 64493 to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
• Use CPT add-on codes 64491, 64492 and 64494, 64495 to report second and third additional levels of paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them.
• Report 64490-64495 once per level, irrespective of the number of drugs injected or whether single or multiple punctures are required to anesthetize the target joint at a given level and side.
• Append modifier KX Requirements specified in the medical policy have been met to the line for all diagnostic injections.
• Append the bilateral modifier 50 to the appropriate code when the provider performs bilateral injections/denervations.
• Do not append multiple procedures modifier 51 to +64491, +64492, +64494, or +64495 because these are add-on codes and exempt from multiple procedure concept.
• When your provider performs injections on both sides of one vertebral level, report the base injection code (64490 or 64493) with modifier 50 Bilateral procedure. If the physician injects a second level bilaterally, report the add-on code (+64491 or +64494), also with modifier 50.

OIG Audits - Improper Payments

Recently released audit findings from the Department of Health and Human Services (HHS) Office of Inspector General (OIG) and show that Medicare did not pay physicians for selected facet-joint denervation sessions in accordance with Medicare requirements. Due to inadequate oversight, the Centers for Medicare & Medicaid Services (CMS) improperly paid physicians a total of $9.5 million for certain facet-joint denervation sessions. Based on OIG recommendations, CMS plans as following

• Direct the Medicare Administrative Contractors (MACs) to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions.
• Instruct the MACs to notify the physicians who received potential overpayments so they can exercise reasonable diligence to identify, report, and return any overpayments per the 60-day rule,
• Assess the effectiveness of oversight mechanisms specific to detecting or preventing improper payments to physicians for facet-joint denervation sessions and modify the oversight mechanisms based on that assessment; and,
• Direct the MACs to review claims for denervation sessions after the OIG audit period (dates of service from January 2019 through August 2020) to recover any improper payments.

This highlights the importance of verifying with your MAC the limitations of coverage's to avoid inappropriate billing for and overuse of spinal facet-joint denervation for pain management.