Superseded Local Coverage Article Billing and Coding

Billing and Coding: Facet Joint Interventions for Pain Management

A57787

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General Information

Article ID
A57787
Article Title
Billing and Coding: Facet Joint Interventions for Pain Management
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
04/25/2021
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 13, Section 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures, Section 20 Payment Conditions for Radiology Services, and Section 30 Computerized Axial Tomography (CT) Procedures

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33930, Facet Joint Interventions for Pain Management. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Diagnostic and Therapeutic Procedures:

Each paravertebral facet level refers to either the facet joint, also called the zygapophyseal joint OR the two medial branch nerves that innervate each zygapophyseal joint.

Each facet level has a pair of facet joints (one on the right side and one on the left side of the spine). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint [intraarticular] injection, or a medial branch block injection, in one session. A bilateral facet nerve intervention is still considered a single level intervention.

For paravertebral spinal nerves and branch injections, image guidance (fluoroscopy or CT) is required for the performance of CPT codes 64490, 64491, 64493, and 64494 with any injection contrast, which is an included component of the code.

As defined by the Current Procedural Terminology (CPT) Professional edition code book, there are two distinct anatomic spinal regions for paravertebral facet injections: cervical /thoracic (codes 64490, 64491) and lumbar/sacral (codes 64493, 64494).

For each initial, single level injection, diagnostic or therapeutic, performed with image guidance (fluoroscopy or CT), use code 64490 (cervical or thoracic) or code 64493 (lumbar or sacral).

For any additional diagnostic or therapeutic procedures on the same day, use add-on codes 64491 (cervical/thoracic) or 64494 (lumbar/sacral) to report second level injections performed with image guidance (fluoroscopy or CT) in addition to the primary procedure codes 64490 or 64493.

Note: Each unilateral or bilateral intervention at any level should be reported as one unit. If an initial bilateral paravertebral facet injection procedure is completed, codes 64490 or 64493, signify by appending the modifier -50.

If completing a bilateral procedure for any of the add on codes, 64491 or 64494, performed on the same day, report the applicable procedure code on two separate lines and append the -RT and -LT modifiers to each line.

For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. Report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.

When an intraarticular facet joint injection is used for facet cyst aspiration/rupture, it should be reported with CPT code 64999. Providers are required to indicate in block 19 of the 1500 claim form or the EMC Equivalent the date of the initial injection procedure and if the injection procedure is being repeated.

For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.

KX modifier requirements:

The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the LCD and indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.

Neurolytic Destruction Procedures (Radiofrequency Ablation):

For destruction of paravertebral facet joint medial branch nerves, image guidance and localization (fluoroscopy or CT) are required and inclusive in codes 64633, 64634, 64635, and 64636.

Per the current CPT Professional edition code book, codes 64633, 64634, 64635, and 64636 are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated. There are two distinct anatomic spinal regions for paravertebral facet destruction: cervical/thoracic (codes 64633, 64634) and lumbar/sacral (codes 64635, 64636). For each initial, single level thermal radiofrequency destruction performed with image guidance (fluoroscopy or CT), use code 64633 (cervical or thoracic) or code 64635 (lumbar or sacral).

For any additional thermal radiofrequency destruction performed on the same day, use add-on codes 64634 (cervical/thoracic) or 64636 (lumbar/sacral) in addition to the primary procedure codes 64633 or 64635.

Note: Each unilateral or bilateral intervention at any level should be reported as one unit.

If initial bilateral paravertebral neurolytic destruction is performed, code 64633 or 64635, signify by appending the modifier -50.

If completing a bilateral paravertebral destruction procedure for any of the add on codes, being performed on the same day, code 64634 or 64636 for second level destruction, report the applicable procedure code on two separate lines and append the -RT and -LT modifiers to each line.

For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. Report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.

Non-thermal facet joint denervation (including chemical, low grade thermal energy [<80 degrees Celsius] or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999.

Note: Report CPT code 64999 when facet cyst aspiration/rupture is performed.

Note: CPT code 64999 is non covered when used to report non thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius) or any form of pulsed radiofrequency.

Note: When reporting CPT code 64999 ensure that the description of the service is included on the claim.

If facet joints are injected with biologicals or other substances not designated for this use the entire claim may deny per CMS IOM Medicare Benefit Policy Manual, Chapter 16, Section 180-Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.

Utilization Parameters

Note: A session is defined as all procedures (i.e., MBB, IA, facet cyst ruptures, and destruction by a neurolytic agent (e.g., RFA) performed on the same date of service.

CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months.

CPT code 64490 through 64494 with the KX modifier will be limited to no more than four (4) sessions, per region, per rolling 12 months.

CPT codes 64633 through 64636 will be limited to no more than two (2) sessions, per region, per rolling 12 months.

Consistent with the LCD, CPT code 64999 may only be reported twice for an intraarticular facet joint injection for a facet cyst aspiration/rupture.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The medical record must include the assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit, relevant medical history, and the results of any pertinent tests/procedures.
  5. Documentation of why the patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic injection procedures.
  6. The scales used to assess the measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Score (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient-Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function.

Coding Information

CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Note: Report CPT code 64999 when facet cyst aspiration/rupture is performed.

The following CPT codes need to be listed separately in addition to a code for the primary procedure: 64491, 64494, 64634, and 64636.

Group 1 Codes
CodeDescription
64490 Inj paravert f jnt c/t 1 lev
64491 Inj paravert f jnt c/t 2 lev
64493 Inj paravert f jnt l/s 1 lev
64494 Inj paravert f jnt l/s 2 lev
64633 Destroy cerv/thor facet jnt
64634 Destroy c/th facet jnt addl
64635 Destroy lumb/sac facet jnt
64636 Destroy l/s facet jnt addl
64999 Nervous system surgery

Group 2

(13 Codes)
Group 2 Paragraph

Note: CPT code 64999 is non-covered when used to report non-thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), or any form of pulsed radiofrequency.

The following CPT/HCPCS codes do not support medical necessity and will not be covered by Medicare.

Group 2 Codes
CodeDescription
64492 Inj paravert f jnt c/t 3 lev
64495 Inj paravert f jnt l/s 3 lev
64999 Nervous system surgery
0213T Njx paravert w/us cer/thor
0214T Njx paravert w/us cer/thor
0215T Njx paravert w/us cer/thor
0216T Njx paravert w/us lumb/sac
0217T Njx paravert w/us lumb/sac
0218T Njx paravert w/us lumb/sac
0219T Plmt post facet implt cerv
0220T Plmt post facet implt thor
0221T Plmt post facet implt lumb
0222T Plmt post facet implt addl

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
50 BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
LT LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)

ICD-10-CM Codes that Support Medical Necessity

Group 1

(20 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 64490, 64491, 64493, 64494, 64633, 64634, 64635, 64636, and 64999 (facet cyst aspiration/rupture).

Note: ICD-10 Codes M71.30 or M71.38 is allowed for facet cyst rupture procedures only.

Group 1 Codes
CodeDescription
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
M47.892 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
M48.12 Ankylosing hyperostosis [Forestier], cervical region
M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14 Ankylosing hyperostosis [Forestier], thoracic region
M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16 Ankylosing hyperostosis [Forestier], lumbar region
M48.17 Ankylosing hyperostosis [Forestier], lumbosacral region
M71.30 Other bursal cyst, unspecified site
M71.38 Other bursal cyst, other site

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
CodeDescription
XX000 Not Applicable

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/25/2021 R2

Final Article published on 03/11/2021 effective for dates of service on and after 04/25/2021. 

10/29/2020 - Draft Article posted.

10/01/2020 R1

Revision Number: 1
Publication: September 2020 Connection
LCR B2020-013

Explanation of Revision: Based on CR 11845 (Annual 2021 ICD-10-CM Update) the Billing and Coding Article was revised to add ICD-10-CM code M25.59 to “ICD-10 Codes that Support Medical Necessity/ Group 1 Codes:”. The effective date of this revision is for dates of service on or after October 1, 2020.

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