Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58403)

CMS National Coverage PolicyN/AArticle Text&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;Refer to the Local Coverage Determination (LCD) L38801 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 GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This policy applies onlyto cervical/thoracic or lumbar facetprocedures 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 two facet joints per level, one on the right side and one 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 one session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as one 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). 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 two levels, either unilateral or bilateral, are allowed per session per spine region (i.e., two (2) unilateral or two (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 two separate lines, with one 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 two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy 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.Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636are 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 (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as one 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 to use modifier 50. Only the ASC Facility itself must 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. 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 injection 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.For RFA the use of moderate anesthesia or MAC may be considered if medically 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 RequirementsThe patients 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 historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)