SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Facet Joint Interventions for Pain Management

A58350

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A58350
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Facet Joint Interventions for Pain Management
Article Type
Billing and Coding
Original Effective Date
04/25/2021
Revision Effective Date
07/07/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and §20 Payment Conditions for Radiology Services.

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Facet Joint Interventions for Pain Management L38765.

The Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to NCCI edits or Hospital Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and National Provider Identifier (NPI) of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.

Coding Guidance: Providers should refer to the applicable American Medical Association (AMA) CPT® Manual to assist with proper reporting of these services.

This article applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).

Diagnostic and Therapeutic Procedures:

Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are 2 facet joints per level, 1 on the right side and 1 on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intra-articular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy)) in 1 session. A bilateral intervention is still considered a single level intervention.

Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.

Regions:

An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT® codes 64490, 64491, 64492) or lumbar\sacral (CPT® codes 64493, 64494, 64495) per the AMA CPT® Manual.

Levels:

64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or computed tomography [CT]). Procedures performed under ultrasound guidance are not covered.

64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.

64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.

Laterality:

Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.

One to 2 levels, either unilateral or bilateral, are allowed per session per spine region (i.e., 2 unilateral or 2 bilateral levels per session).

For services performed in the Ambulatory Surgery Center (ASC), physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.

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 2 initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the related 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.

Therapeutic injections:

Documentation of why patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic treatment.

Chemodenervation of nerve:

Codes 64633, 64634, 64635, 64636 are reported per joint, not per nerve. Although 2 nerves innervate each facet joint, only 1 unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT® Manual 2020).

Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.

Region:

An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT® codes 64633 and 64634) or lumbar/sacral (CPT® codes 64635 and 64636) per the AMA CPT® Manual.

For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use 64633.

Levels:

64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT).

64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.

Laterality:

For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.

For services performed in the ASC, physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 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. Code 64999 is non-covered when used to report non-thermal facet joint denervation.

If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Medicare Benefit Policy Manual, Chapter 16, §180.

Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is not considered medically reasonable and necessary during facet injections.

For RFA and facet cyst aspiration/rupture, the use of moderate anesthesia or MAC may be considered if medical necessity is clearly established. Documentation must explain the medical necessity for sedation, and frequent reporting of these services together may trigger focused medical review.

Documentation Requirements

The patient’s medical record should include, but is not limited to:

  • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
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)
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(18 Codes)
Group 1 Paragraph

Note: 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.

Medicare is establishing the following limited coverage for CPT/HCPCS codes: 64490, 64491, 64493, 64494, 64633, 64634, 64635, and 64636.

Group 1 Codes
Code Description
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
N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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.

Code Description

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N/A

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.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/07/2024 R5

The related Facet Joint Interventions for Pain Management L38765 LCD is being presented for notice. Under Article Text removed the verbiage “Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and, therefore, may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be considered on appeal” and added “Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is not considered medically reasonable and necessary during facet injections. For RFA and facet cyst aspiration/rupture, the use of moderate anesthesia or MAC may be considered if medical necessity is clearly established. Documentation must explain the medical necessity for sedation, and frequent reporting of these services together may trigger focused medical review.” Under ICD-10-CM Codes that Support Medical Necessity Group 1: Paragraph removed the verbiage “Note: ICD-10-CM Codes M71.30 or M71.38 are allowed for facet cyst rupture procedures only.” Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes deleted M71.30 and M71.38. Under CPT/HCPCS Modifiers Group 1: Codes 50, KX, LT and RT were added when presented for comment

04/08/2024 R4

Under Article Text under Diagnostic and Therapeutic Injections subheading, deleted the sentence: “One medial branch block is counted as 2 facet joint injections” due to a typographical error. This revision is retroactive effective for dates of service on or after 4/25/21.

04/13/2023 R3

Under CMS National Coverage Policy added regulation section headings and the following regulation: “CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.” Under Article Text in the fifth paragraph verbiage was changed from “This policy applies...” to “This article applies….” Formatting, punctuation and typographical errors were corrected throughout the article. Acronyms were inserted where appropriate throughout the article.

11/06/2022 R2

Under Article Text revised verbiage regarding physician use of modifier 50 when services are performed in an ASC, and added language regarding the use of moderate or deep sedation, general anesthesia, and monitored anesthesia (MAC).

05/01/2022 R1

Under Article Text deleted the verbiage “This information does not take precedence over NCCI edits" from the second paragraph.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L38765 - Facet Joint Interventions for Pain Management
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
07/23/2024 07/07/2024 - N/A Currently in Effect View
06/26/2024 07/07/2024 - N/A Superseded View
05/17/2024 07/07/2024 - N/A Superseded You are here
04/08/2024 04/08/2024 - 07/06/2024 Superseded View
04/03/2023 04/13/2023 - 04/07/2024 Superseded View
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Keywords

  • Facet Joint Interventions
  • Pain Management