Billing and Coding: Facet Joint Interventions for Pain Management

Refer to the Local Coverage Determination (LCD) L38841 Facet Joint
Interventions for Pain Management, for reasonable and necessary requirements
and frequency limitations.

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 National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare. For services requiring a referring/ordering physician, the
name and 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 AMA CPT Manual to assist with proper
reporting of these services.

This policy 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 procedure).

Diagnostic and Therapeutic injections:

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
(intraarticular) 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 CT). Procedure
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 to 2 bilateral levels per session).

For services performed in the ASC, physicians must continue to use 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 policy 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 focus medical review.  
  
Therapeutic injections:

Documentation of why patient is not a candidate for RFA must be submitted for
therapeutic treatment upon request.  
  
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 paraveterbral
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 to use 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 Benefit Policy Manual
Chapter 16: Section 180.

Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia
Care (MAC) is usually unnecessary or rarely indicated for facet joint
injection 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.

**Documentation Requirements**  
The patient's medical record should include but is not limited to:

  * The assessment of the patient by the ordering 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.)