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Medicare Provides Guidance on Proper Coding of Facet Joint Injections

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 Policy

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:

  • The pain does not have a strong radicular component.
  • There is no associated neurological deficit and the pain is aggravated by hyperextension, rotation or lateral bending of the spine, depending on the orientation of the facet joint at that level.

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:

  • CPT 64490 -Injections(s), diagnostic 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
  • CPT 64491 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level
  • CPT 64492 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s)
  • CPT 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
  • CPT 64494 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
  • CPT 64495 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s)
  • CPT 64622 - Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level
  • CPT 64623 - Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (list separately in addition to code for primary procedure)
  • CPT 64626 - Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level
  • CPT 64627 - Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
  • CPT 64999 - Unlisted procedure, nervous system
  • CPT 77003 - Fluoroguide for spine inject

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.

Is your practice struggling with proper coding and billing for pain management services? Contact PGM Billing, a leader in providing pain management billing solutions that help ensure proper reimbursement, reduce costs and streamline practice operations, to learn what our team of certified coders and billers can do for your practice.

Certified Medical Coder Salaries Now Average More Than $50,000

Salaries for certified medical coding professionals increased an average of 8.4% in 2014 to $50,775 annually, according to the results of the 2014 annual coder salary survey conducted by AAPC.

More than 14,000 medical coders responded to the survey. Other highlights include the following:

  • Coders with a bachelor's degree earned an average of $54,522 in 2014, more than $10,000 higher than coders without a college degree.
  • Coders with 31 or more years of experience earn an average of $68,868 per year. Those with 26-30 years average $66,033. Coders with 21-25 years experience earn $63,558 on average.
  • Coders in medium-sized group practices saw a 10 percent increase in salary, earning $46,762 on average.

View the results of the 2014 coder salary survey (pdf).

Staffing costs are one of the highest expenses for healthcare providers. Not only does this take salaries into consideration, but it also includes expenses associated with benefits, training, and any IT equipment and software needed for staff members to perform their job. With staff salaries increasing significantly, more practices and surgery centers are choosing to outsource their medical billing to a medical billing service such as PGM Billing.

Since 1981, PGM has provided practice management and medical billing services to physicians and facilities nationwide. Its team of certified medical coders and billers helps increase a provider's revenue by boosting collection rates, reducing denials and delays in payment, and cutting costs. To learn more about what PGM can do for your organization, contact us today.

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