Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57787)

CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-04, Medicare Claims Processing Manual,Chapter 12, Section 40.7 Claims for Bilateral SurgeriesChapter 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) ProceduresSocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL33930, Facet Joint Interventions for Pain Management. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice: 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.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 or Ambulatory Surgery Center (ASC):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 procedures).Diagnostic and Therapeutic Procedures:CPT Codes 64490, 64491, 64492, 64493, 64494, 64495 describe the introduction/ injection of a diagnostic or therapeutic agent into the paravertebral facet joint or into the nerves that innervate that joint by level.Facet joints are paired joints with one pair at each vertebral level (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 (IA), a medial branch block injection (MBB), or the medial branch radiofrequency ablation [neurotomy]) in one session. A bilateral intervention is still considered a single level facet intervention.When determining a level, count the number of facet joints injected not the number of nerves injected. Therefore, if multiple nerves of the same facet joint are injected it would be considered as a single level. The add-on codes are reported when second, third, or additional levels are injected during the same session.When the procedure is performed bilaterally at the same level, report one unit of the primary code with modifier -50.When the procedure is performed bilaterally at one level and unilaterally at a different level report one unit of the primary procedure. If the procedure is performed unilaterally at different levels report one unit of the primary procedure and the appropriate add-on code.Regions: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).Levels:CPT code 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.CPT code 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.CPT code 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 unilateral or two 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.Chemodenervation of nerve:CPT codes 64633, 64634, 64635, 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 (AMA CPT Manual 2023).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 CPT code 64633.Levels:CPT code 64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT).Use CPT code 64634 or 64636 to report each additional facet joint at a different vertebral level in the same spinal region.CPT code 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 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 rarely medically reasonable and necessary for facet injections and not routinely reimbursable. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be given.For radiofrequency ablation (RFA) the use of moderate sedation 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.Utilization ParametersNote: 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 sessions, per region, per rolling 12 months.CPT codes 64490 through 64494 with the KX modifier will be limited to no more than four sessions, per region, per rolling 12 months.CPT codes 64633 through 64636 will be limited to no more than two sessions, per region, per rolling 12 months.Documentation RequirementsAll 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 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.)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.