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Medicare has provided guidance on how to properly code facet joint injections after its Recovery Audit Program identified claims resulting in overpayments.
This is according to a recent issue of Medicare Quarterly Provider Compliance Newsletter (pdf), a newsletter from CMS developed to help providers understand the major findings identified by Medicare administrative contractors, recovery auditors and other governmental organizations.
As Medicare notes, the local coverage determination policy indicates approved covered conditions for facet joint injections. In automated reviews, recovery auditors identified claims where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies. An overpayment exists when a provider bills for a facet joint injection with an ICD-9 code that is not included in the list of covered ICD-9 codes within the applicable LCD documents for facet joint injections.
Medicare notes that it will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document and confirm suspicions of posterior element biomechanical pain of the spine. Hallmarks of posterior element biomechanical pain are:
A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebrae. The facet joint is noted at a specific level by the vertebrae that form it (e.g., C4-5 or L2-3). It is further noted that there are two facet joints at each level, left and right. The covered CPT codes reviewed are:
Discussion of Codes
Due to the diagnostic nature of facet blocks, precise localization is necessary. Therefore, Medicare notes it is expected that use of the facet codes (CPT 64490-64495) would require radiologic localization (i.e., fluoroscopy). An injection may be placed in the facet joint itself or around the medial branch nerve innervating the joint. In general, it is believed that two to three medial branch nerves innervate each lumbar facet joint and two nerves innervate each cervical or thoracic facet joint. These nerves are the branches of the posterior division of the spinal nerves, located immediately above and below the joint.
– CPT codes 64490 and 64493 are intended to be used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve.
– CPT codes 64491, 64492, and 64494, 64495 are intended to report second and third additional levels paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them as defined by the AMA CPT Committee.
– Codes 64490-64495 are unilateral procedures.
– When bilateral injections are performed (e.g., injections performed at both the left and right paravertebral facet joints), then the bilateral modifier 50 should be appended to the appropriate code. Note that the multiple procedures modifier 51 should not be appended to the add-on codes 64491, 64492, 64494, or 64495 because these are add-on codes and exempt from multiple procedure concept.
The cervical/thoracic facet injection codes (64490, 64491, and 64492) and lumbar/sacral facet joint injection codes (64493, 64494, and 64495) are reported once when the injection procedure is performed irrespective of whether a single or multiple puncture is required to anesthetize the target joint at a given level and side. To clarify, only one facet injection code should be reported at a specific level and side injected (e.g., right L4-5 facet joint), regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level.
The MLN Matters article on facet joint injection services (pdf) clarifies the appropriate use of modifier 50 and add-on codes for facet joint injections.
– Physicians who perform facet joint injections on both the right and left sides of one level of the spine must use modifier 50 with the appropriate CPT codes when submitting claims. If a physician performs multiple bilateral injections, modifier 50 should accompany each facet CPT joint injection code.
– Physicians who perform facet joint injections on multiple levels on the same side of the spine must use the CPT add-on codes to represent these additional levels injected, instead of using modifier 50.
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