The facet joints connect the vertebrae of the lower back spine that hold the vertebral column together and provide support. Facet joint disorders such as spinal osteoarthritis, facet joint arthritis, facet joint disease, and facet syndrome can cause chronic spinal pain. These facet joints bear a large amount of stress and weight, making them vulnerable to degeneration and injury. Facet joint interventions such as intraarticular injections, medial branch nerve blocks, and neurotomy (radiofrequency and cryoneurolysis) are used to manage chronic facet-mediated spinal pain. Providers can take support from experienced medical billing outsourcing companies to report these interventions on the medical claims using accurate CPT codes.
Facet joint interventions are considered medically necessary for the treatment of chronic pain in patients. A diagnostic facet joint procedure helps to diagnose whether the patient has facet syndrome. Pain from a facet in the lower back may initially be acute and become chronic over time. Facet joint injections are used to treat pain stemming from a specific facet joint. The injection is typically delivered into the capsule that surrounds the facet.
Key factors that can cause the pain in these joints include poor posture, age-related degeneration of the intervertebral disc, fall, acute trauma from an accident, sports-related injury, or even chronic lower back injury due to repetitive overuse or microtrauma to the facets.
Major symptoms of lumbar facet joint disorders include localized or radiating pain, tenderness on palpation, stiffness, effect of posture and activity, and stiffness. Diagnosis may involve medical exam and imaging tests such as standard radiographs, MRI scans, CT scans, SPECT scans, and more. Treatment options may include nonsurgical treatments, physical therapy, medications, injection therapy, and TENS therapy.
Coding Facet Joint Interventions
The procedural codes for facet joint injections are –
- 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
- +64491 second level (List separately in addition to code for primary procedure)
- +64492 third and any additional level(s) (List separately in addition to code for primary procedure)
- 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
- +64494 second level (List separately in addition to code for primary procedure)
- +64495 third and any additional level(s) (List separately in addition to code for primary procedure)
Facet joint denervation
Facet joint denervation is used to treat central neck or back pain caused by arthritis or injury to the facet joints. The procedure involves using a special needle with a heated tip to destroy the nerves that supply the joints.
Codes to report facet joint denervation:
- 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
- + 64634 Each additional facet joint (List separately in addition to code for primary procedure)
- 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
- +64636 each additional facet joint (List separately in addition to code for primary procedure)
AAPC has highlighted the following coding guidelines when reporting facet joint interventions –
- Codes 64490-64495 are unilateral procedures.
- Use CPT® codes 64490 and 64493 to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
- Use CPT® add-on codes 64491, 64492 and 64494, 64495 to report second and third additional levels of paravertebral facet joints and not each additional nerve.
- Report 64490-64495 once per level, irrespective of the number of drugs injected or whether single or multiple punctures are required to anesthetize the target joint at a given level and side.
- Append modifier KX Requirements specified in the medical policy have been met to the line for all diagnostic injections.
- Append the bilateral modifier 50 to the appropriate code when the provider performs bilateral injections/denervations.
- Do not append multiple procedures modifier 51 to +64491, +64492, +64494, or +64495 because these are add-on codes and exempt from multiple procedure concept.
- When the provider performs injections on both sides of one vertebral level, report the base injection code (64490 or 64493) with modifier 50 Bilateral procedure. If the physician injects a second level bilaterally, report the add-on codes twice. CPT® code book recommends not to report modifier 50 in conjunction with 64491, 64492, 64494, 64495.
- Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Imaging guidance coding
- When reporting facet joint codes, coders may not bill separately for the image guidance when done via fluoroscopy or CT.
- If the doctor uses ultrasound guidance for the above procedures, coders must report the facet joint injection using 0213T-0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance.
Before providing treatment, it is important for pain management physicians to verify whether the patient’s insurance covers these interventions. Proper patient eligibility verification helps prevent claim denials and obtain reimbursement on time.