CPT/HCPCS Codes
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
Paravertebral Facet Joint Injection
- Each CPT code listed (single level, second level, third and any additional levels) may be billed with a Modifier 50 when injecting a level bilaterally. For one level unilateral or bilateral CPT codes 64490 or 64493 should be used. If the facet joint injection is performed at more than one level unilateral or bilateral
CPT codes 64491, 64492, 64494 or 64495 should be used for the additional levels. For bilateral procedures Modifier 50 should be appended to the procedure codes with number of services of one. - Use the appropriate CPT code in Item 24D on the CMS-1500 claim form (or electronic equivalent) and link it to the applicable ICD-9-CM code listed above under the ICD-9-CM Codes that Support Medical Necessity section.
- Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64490- 64495.
- If the injection is made around or into the spinal nerve, the service should be billed as a paravertebral nerve injection.
5 When destruction of the facet joint nerve is performed following the blockage, only the codes for the nerve destruction should be billed since their allowance includes that of the facet nerve blockage procedure.
Paravertebral Facet Joint Denervation Guideline
- If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.
- Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).
- Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.
Overview
Paravertebral facet joint block is used to both diagnose and treat lumbar zygapophysial (facet joint) pain. Facet joint pain syndrome is a challenging diagnosis as there are no specific histories, physical examination, or radiological imaging findings that point exclusively to the diagnosis. However, this diagnosis is considered if the patient describes nonspecific, achy, back pain that is located deep in the paravertebral area. A detailed physical examination of the spine should be performed on all patients. Radiological imaging is often done as part of the workup of persistent chronic back pain to exclude other diagnoses. Facet joint block is one method used to document/confirm suspicions of posterior elemental biomechanical pain of the spine.
Often the patient presents with chronic neck, thoracic or low back pain that lacks a strong radicular component, has no associated neurologic deficits, and is often aggravated by hyperextension or rotation of the spine. This policy defines chronic pain as continuous or intermittent pain that has been unresponsive to conservative measures, persisting three months or more. Facet joint injections must be performed under imaging guidance to assure accurate placement of the needle in the facet joint or on the medial nerve branch of the facet joint. A long acting local anesthetic or corticosteroid agent is injected to temporarily denervate the facet joint. After a satisfactory block has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms.
Diagnostic blocks are used to assess the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome and to localize the nerve(s) responsible for the pain or neuromuscular dysfunction, particularly when multiple sources of pain are potentially present.
Guidelines
• Patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as tolerated).
• Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication
• There is no non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, infection, or significant deformity.
• Clinical assessment implicates the facet joint as the putative source of pain.
Please refer to the related CMS Local Coverage Determinations (LCDs) for additional guidelines and limitations specific to diagnostic and therapeutic facet joint injections. Medicare does not expect that an epidural block or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on same day could lead to improper or lack of diagnosis. Coverage will be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management.
Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by CPT codes 64490, 64491, 64492, 64493, 64494, and 64495. For paravertebral spinal nerves and branches – image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of CPT codes 64490, 64491, 64492, 64493, 64494, and 64495.
The CPT codes included in this policy include CT or fluoroscopic guidance; do not bill these codes unless CT or fluoroscopic guidance is performed.
Indications and Limitations of Coverage and/or Medical Necessity Facet Joint Blocks:
The paravertebral facet joint, known as the zygapophysial joint is made up of two superior processes (extensions of bone projecting upward), interconnecting with two inferior processes (which project downward) from the vertebra directly above.
A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. For the purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right.
For the purpose of this LCD an anatomical region is defined as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495). A facet joint level refers to the facet joint or the nerves (e.g., medial branch nerves) innervating that joint.
Facet joint block is one of the methods used to document/confirm suspicions of posterior elemental biomechanical pain of the back. The patient with this condition usually has back pain that does not have a strong radicular component, no associated neurologic deficit and the pain is aggravated by hyperextension of the spine.
Facet joint injections are considered medically necessary for the diagnosis or treatment of chronic pain that has failed conservative therapy.
During this procedure a needle is placed in the facet joint under fluoroscopic or CT guidance and a long acting local anesthetic agent is injected in the facet joint or around or into the nerve supplying the joint, to temporarily anesthetize the facet joint. After satisfactory blockade of the pain has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged significant pain relief of the back pain suggests that facet joints were the source of the symptoms and appropriate treatment may be prescribed.
A series of two injections may be medically necessary for diagnostic blocks to establish consistency of results, particularly if diagnostic blocks are to be followed by facet joint denervation.
Multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. It is reasonable to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first procedure fails to produce the desired effect or rules out the diagnosis, the provider may
proceed to the next logical test or treatment if desired.
Accordingly, providing a combination of epidural block, facet joint blocks, bilateral sacroiliac joint injections, lumbar sympathetic blocks or providing more than three levels of facet joint blocks to a patient on the same day is considered not reasonable or necessary. Such therapy can lead to an improper diagnosis or unnecessary treatment.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
This policy does not address sacral conditions or injections or neurotomies. Sacral injections are not subject to the requirements of this LCD.
The paravertebral facet joint, known as the zygapophysial joint is made up of two superior processes, extensions of spine projecting upward, interconnecting with two inferior processes, which project downward from the vertebra directly above.
For the purpose of this LCD an anatomical region is defined as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495). A facet joint level refers to the facet joint or the nerves (e.g., medial branch nerves) innervating that joint.
Limitations of Coverage:
- It would not be considered appropriate to report acupuncture or variations of those techniques with any of the CPT codes in this policy.
- It is not considered reasonable and necessary for intraarticular facet joint injections or medial branch blocks to routinely require conscious sedation or Monitored Anesthesia Care (MAC). Frequent use of MAC or conscious sedation with intraarticular facet joint injections or medial branch blocks may result in prepayment or post payment medical review.
- Facet joint interventions performed under ultrasound guidance are not considered reasonable and necessary and will not be covered.
- Radiculopathy should be ruled out by physical or electrophysical examination.
- Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.
- Intraarticular and/or extraarticular facet joint Prolotherapy is not covered.
- Medicare does not expect that an epidural block or sympathetic block would be provided to a patient on the same day as facet joint injections. Multiple blocks on the same day could lead to improper or lack of diagnosis. Coverage will be extended for only one type of procedure during one day/session of treatment unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management.
- Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by CPT codes 64490, 64491, 64492, 64493, 64494, and 64495. For paravertebral spinal nerves and branches – image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of CPT codes 64490, 64491, 64492, 64493, 64494, and 64495.
- The medical effectiveness of Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents has not been verified by scientifically controlled studies. Accordingly, these modalities are not considered reasonable and necessary and are not covered services . (Please refer to CMS publication 100- 03, Medicare National Coverage Determination Manual, Chapter 1: Section 150.7)
- The services included in this policy include CT or fluoroscopic guidance. Therefore, it is not considered reasonable and necessary to report any of the services in this policy if CT or fluoroscopic guidance was not performed. Services performed with Magnetic Resonance Imaging (MRI) or services performed without any guidance will be considered not reasonable and necessary and therefore will be non-covered.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Medicare does not consider it reasonable and necessary for services represented by CPT codes 64490 and 64493 (with or without the 50 modifier) inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations to be rendered more than five (5) times in a year in the cervical/thoracic spine and five (5) in the lumbar spine.
