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 of service (UOS).
If an initial (64490 or 64493) or second level add-on (64491 or 64494) paravertebral facet injection procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these procedures bilaterally (modifier -50).
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 are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, 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 UOS.
If initial (64633 or 64635) or each additional add-on (64634 or 64636) paravertebral neurolytic destruction procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these services bilaterally (modifier -50).
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
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- 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.
- 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.
- 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.
- Documentation of why the patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic injection procedures.
- 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.
