Procedure code and Description
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
64490 – Replaces 64470 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 – average fee payment – $200 – $210
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 (List separately in addition to code for primary procedure) – average fee payment – $90 – $110
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) (List separately in addition to code for primary procedure) – average fee payment – $90 – $110
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
Summary of Direct Crosswalk Codes Decision Regarding Facet Joint Injection:
There were four codes (64470, 64472, 64475, and 64476) active prior to January 1, 2010 for facet joint injection. All four codes expired as of December 31, 2009. Six new replacement codes (64490-64495) were created effective January 1, 2010 to replace the four facet joint injection codes listed above. Instead of one code for any additional level after the first level, CPT broke out the secondary level and the third and any additional level into two separate codes. Due to the unique nature of this situation, UnitedHealthcare intends to:
** Crosswalk the contracted fee from 64470 to 64490
** Crosswalk the contracted fee from 64472 to 64491 and 64492
** Crosswalk the contracted fee from 64475 to 64493
** Crosswalk the contracted fee from 64476 to 64494 and 64495
Epidural Steroid Injections
** Epidural steroid injection is proven and medically necessary when used for the treatment of acute and sub-acute sciatica or radicular pain of the low back caused by spinal stenosis, disc herniation or degenerative changes in the vertebrae.
Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met:
o The pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and
o The pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy.
** Epidural steroid injection is unproven and not medically necessary for all other indications of the lumbar spine.
There is a lack of evidence from randomized controlled trials indicating that epidural steroid injections effectively treat patients with lumbar pain not associated with sciatica or radicular pain.
Note: This policy does not apply to obstetrical epidural anesthesia utilized during labor and delivery. Facet Joint
Injections
** Diagnostic facet joint injection and/or facet nerve block (e.g., medial branch block) is proven and medically necessary when used to localize the source of pain to the facet joint in persons with spinal pain.
** Therapeutic facet joint injection is unproven and not medically necessary for the treatment of chronic spinal pain.
Clinical evidence about the very existence of facet joint syndrome is conflicting, and evidence from studies is inadequate regarding the superiority of periodic facet joint injections compared to placebo in relieving chronic spinal pain (pain lasting more than 3 months).
Diagnostic Occipital Nerve Blocks
Greater occipital nerve blocks have been advocated as a diagnostic test for cervicogenic headache and occipital neuralgia. However, criteria and standards for diagnostic occipital nerve blocks remain to be defined. There are no well-designed clinical trials that clearly indicate that injection of the greater occipital nerve can be used as a specific diagnostic test for headaches and occipital neuralgia.
The Occipital Nerve Stimulation for the Treatment of Intractable Chronic Migraine Headache (ONSTIM) trial, was a multicenter, randomized feasibility study of occipital nerve stimulation (ONS) for treatment of intractable chronic migraine headache that was published in 2011. The trial was designed to evaluate the study design and did not have a single primary end point. One hundred ten patients were enrolled, and patients who had a positive response to a short-acting occipital nerve block were randomized as follows: 33 to adjustable stimulation (AS), 17 to preset stimulation (PS) of 1 min/d, and 17 to medical management (MM). At the 3-month evaluation, the responder rate (percentage of patients who achieve 50% or more reduction in number of headache days per month or a 3-point or greater reduction in average overall pain intensity compared with baseline) was 39% in the AS group, 6% in the PS group, and 0% in the MM group. Lead migration occurred in 12 of 51 (24%) of subjects and 3 subjects required hospitalization for adverse events (infection, lead migration, nausea). Limitations of the study include a short observation period and the inability to effectively blind subjects and investigators to treatment group.
DEFINITIONS
Acute Low Back Pain: Low back pain present for up to six weeks. The early acute phase is defined as less than two weeks and the late acute phase is defined as two to six weeks, secondary to the potential for delayed-recovery or risk phases for the development of chronic low back pain. Low back pain can occur on a recurring basis. If there has been complete recovery between episodes, it is considered acute recurrent.
Subacute Low Back Pain: Low back pain with duration of greater than six weeks after injury but no longer than 12 weeks after onset of symptoms. (Goertz et al. 2012) APPLICABLE CODES
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.
Coverage Indications, Limitations, and/or Medical Necessity
Facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document/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. For 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). It is further noted that there are two (2) facet joints at each level, left and right.
Introduction:
This policy does not address sacral conditions or injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 code M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, are not subject to the requirements of this LCD.
Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints and the MB nerves from the two adjacent dorsal rami innervate each joint. [Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve; and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.]
Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.
Definitions
A zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint.
A “session” is defined as all injections/blocks/RF procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and RF ablations.
A “region” is all injections performed in cervical/thoracic or all injections performed in lumbar (not sacral) spinal areas.
“Diagnosis” of facet-mediated pain requires the establishment of pain relief following dual medial branch blocks (MBBs) performed at different sessions. Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source.
- 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.
During a paravertebral facet joint block procedure, a needle is placed in the facet joint or along the medial branches that innervate the joints under fluoroscopic guidance and a local anesthetic and/or steroid is injected. After the injection(s) have been performed, the patient is asked to indulge in the activities that usually aggravate his/her pain and to record his/her impressions of the effect of the procedure. Temporary or prolonged abolition of the pain suggests that the facet joints are the source of the symptoms and appropriate treatment may be prescribed in the future. Some patients will have long-lasting relief with local anesthetic and steroid; others will require a denervation procedure for more permanent relief. Before proceeding to a denervation treatment, the patient should experience at least a 50 percent reduction in symptoms for the duration of the local anesthetic effect.
Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fails to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495).
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.
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Indications
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.
General Procedure Requirements:
Pre-procedural documentation must include a complete initial evaluation including history and an appropriately focused musculoskeletal and neurological physical examination. There should be a summary of pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.
A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain assessments. With RF neurotomy, electrode position, cannula size, lesion parameters, and electrical stimulation parameters and findings must be specified and documented.
Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed.
A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images which adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in which using contrast is contra-indicated, such as patients with documented contrast allergies), must be retained and submitted if requested.
In order to maintain target specificity, total IA injection volume must not exceed 1.0 mL per cervical joint or 2 mL per lumbar joint, including contrast. Larger volumes may be used only when performing a purposeful facet cyst rupture in the lumbar spine.
Total MBB anesthetic volume shall be limited to a maximum of 0.5 mL per MB nerve for diagnostic purposes and 2ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and 2ml for therapeutic purposes.
In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or dexamethasone or equivalents shall be injected during any single session.
Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may be acceptably performed without steroids.
Provider Qualifications
Provider Qualifications’ requirements must be met. Patient safety and quality of care mandate that healthcare professionals who perform Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy are appropriately experienced and/or trained to provide and manage the services. The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) underscores this point and states that “reasonable and necessary” services must be “ordered and/or furnished by qualified personnel.” Services will be considered medically reasonable and necessary only if performed by appropriately experienced and/or formally trained providers.
The following training requirement applies only to those providers who have not provided these specific interventional pain management services on a regular basis (at least two times per month) during the ten years prior to the effective date of this LCD as may be established by claims billings. A basic requirement of payment is training and/or credentialing by a formal residency/fellowship program and/or other training program that is accredited by a nationally-recognized body and whose core curriculum includes the performance and management of the procedures addressed in this policy. Recognized accrediting bodies include only those whose program accreditation gains the trainee eligibility to sit for a healthcare-related licensing exam or licensing itself, which in turn allows the licensee to perform these procedures. At a minimum, training must cover and develop an understanding of anatomy and drug pharmacodynamics and kinetics, the technical performance of the procedure(s) and utilization of the required associated imaging modalities, and the diagnosis and management of potential complications from the intervention.
The following credentialing requirement applies to all providers of the services addressed in this policy. If the practitioner works in a hospital facility at any time and/or is credentialed by a hospital for any procedure, the practitioner must be credentialed to perform the same procedure in the outpatient setting.
Diagnostic Facet Joint Injections
Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections.
A second confirmatory MBB is allowed if documentation indicates the first MBB produced= 80% relief of primary (index) pain and duration of relief is consistent with the agent employed.
Intraarticular facet block will not be reimbursed as a diagnostic test unless medial branch blocks cannot be performed due to specific documented anatomic restrictions.
Therapeutic Injections
Either intraarticular injections or medial branch blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. Injections may be repeated if the first injection results in significant pain relief (> 50%) for at least 3 months. (See Limitations section for total number of injections that may be performed in one year.)
Recurrent pain at the site of previously treated facet joint may be treated without additional diagnostic blocks if > 50% pain relief from the previous block(s) lasted at least 3 months.
Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):
Only when dual MBBs provide = 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered.
Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced = 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months.
Limitations of Coverage:
A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine.
For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.
Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.
Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 are="" as="" celsius="" covered.="" degrees="" font="" not="" pulsed="" rf="" well="">
Intraarticular and/or extraarticular facet joint prolotherapy is not covered.
Group 1 Paragraph: N/A Group 1 Codes: 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 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 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) (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 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 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 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) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT 64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, 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 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Group 2 Paragraph: Note the following Category III codes are considered non-covered. Please refer to the statement, “Facet joint interventions performed under ultrasound guidance will not be reimbursed” under General Procedure Requirements in the Coverage Indications, Limitations and/or Medical Necessity section above. Group 2 Codes: 0213T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL 0214T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0215T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0216T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL 0217T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0218T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; 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
1. 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.
2. 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.
3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64490- 64495.
4. 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
1. 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.
2. 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).
3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.
Summary of Direct Crosswalk Codes Decision Regarding Facet Joint Injection:
There were four codes (64470, 64472, 64475, and 64476) active prior to January 1, 2010 for facet joint injection. All four codes expired as of December 31, 2009. Six new replacement codes (64490-64495) were created effective January 1, 2010 to replace the four facet joint injection codes listed above. Instead of one code for any additional level after the first level, CPT broke out the secondary level and the third and any additional level into two separate codes. Due to the unique nature of this situation, UnitedHealthcare intends to:
** Crosswalk the contracted fee from 64470 to 64490
** Crosswalk the contracted fee from 64472 to 64491 and 64492
** Crosswalk the contracted fee from 64475 to 64493
** Crosswalk the contracted fee from 64476 to 64494 and 64495
Facet/Medial Branch Block Injections:
** Therapeutic Facet/Medial Branch Block Injections are not covered.
** Diagnostic Facet/Medial Branch Block Injections will have a limit of four per calendar year applied to CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.
** Facet/Medial Branch Block Injections must be performed by a physician/practitioner as required by T.C.A 63-7-126 (attached).
** Medical records are required when submitting a claim with CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.
For claims with dates of service on or after Oct. 1, 2013, UnitedHealthcare Community Plan will make changes to the following member benefits:
* Facet/Medial Branch Block Injections
* Trigger Point Injections
* Epidural Steroid Injections
* Urine Drug Screens
* TENS Unit for Chronic Lower Back Pain (CLBP)
Facet/Medial Branch Block Injections:
* Therapeutic Facet/Medial Branch Block Injections are not covered.
* Diagnostic Facet/Medial Branch Block Injections will have a limit of four per calendar year applied to CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.
* Facet/Medial Branch Block Injections must be performed by a physician/practitioner as required by T.C.A 63-7-126 attached).
* Medical records are required when submitting a claim with CPT codes 64490, 64491, 64492, 64493, 64494 and 64495.
The Reporting of Bilateral Procedures Using Modifier -50
Modifier – 50 is used by providers and suppliers, other than ambulatory surgical centers (ASCs), to report bilateral procedures when the term “bilateral” is not included in the code descriptor of a CPT® code. Because this modifier is used when specific pain medicine procedures are performed bilaterally, this topic will be of particular interest to ASA members practice pain medicine. The intent of this modifier is to report an appropriate unilateral procedure when performed bilaterally, and there is no bilateral CPT code to report what has been done. The Centers for Medicare and Medicaid Services (CMS) defines a bilateral service as one in which the same procedure is performed on both sides of the body during the same operative session or on the same day. These bilateral procedures are performed either on the same operative area (e.g. breast, nose, eyes) or in separate operative areas (e.g. feet, arms, legs).
In the past, Medicare allowed bilateral procedures when the term “bilateral” was not included in the code descriptor, to be reported by different methods that were correct only in certain circumstances. For example, CPT notes that facet joint injections as described by codes 64490 – 64495 are unilateral procedures; modifier 50 is to be appended when the procedure is done bilaterally, Common methods to report the scenario in which the injection was done bilaterally at one single lumbar level were:
* two units of service (UOS) reported on a single line with no modifier
Example:
64493, Units=2
* one UOS on each of the separate lines using the modifiers RT and LT;
* Example:
64493–RT, Units = 1
64493–LT, Units = 1
* one UOS on one line using the modifier -50
Example:
64493-50, Units=1
Recently, CMS implemented a Medically Unlikely Edit (MUE) that will render the reporting of bilateral procedures where the term “bilateral” is not included in the CPT code descriptor, as unpayable when reported on two claim lines using the RT and LT modifiers or by reporting two units of service on a single line with no modifier. The National Correct Coding Initiative (NCCI) and the Medicare Claims Processing Manual now require the practitioner or suppler to report these procedures using a single unit of service on a single claim line using the -50 modifier – per the third bullet point above
ICD-10 Codes that Support Medical Necessity
M25.50 Pain in unspecified joint
M47.14 Other spondylosis with myelopathy, thoracic region
M47.15 Other spondylosis with myelopathy, thoracolumbar region
M47.16 Other spondylosis with myelopathy, lumbar region
M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M47.28 Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.891 Other spondylosis, occipito-atlanto-axial region
M47.892 Other spondylosis, cervical region
M47.893 Other spondylosis, cervicothoracic region
M47.894 Other spondylosis, thoracic region
M47.895 Other spondylosis, thoracolumbar region
M47.896 Other spondylosis, lumbar region
M47.897 Other spondylosis, lumbosacral region
M47.898 Other spondylosis, sacral and sacrococcygeal region
M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region
M54.04 Panniculitis affecting regions of neck and back, thoracic region
M54.05 Panniculitis affecting regions of neck and back, thoracolumbar region
M54.06 Panniculitis affecting regions of neck and back, lumbar region
M54.07 Panniculitis affecting regions of neck and back, lumbosacral region
M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region
M54.09 Panniculitis affecting regions, neck and back, multiple sites in spine
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M62.830 Muscle spasm of back
M96.1 Postlaminectomy syndrome, not elsewhere classified
Z79.01* Long term (current) use of anticoagulants
ICD-9-CM Codes That Support Medical Necessity
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721.0–721.3
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Cervical spondylosis without myelopathy
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721.41–721.42
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Spondylosis with myelopathy lumbar region
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721.90
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Spondylosis of unspecified site without mention of myelopathy
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722.10–722.11
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Displacement of thoracic or lumbar intervertebral disc without myelopathy
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722.4
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Degeneration of cervical intervertebral disc
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722.51–722.52
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Degeneration of thoracic or lumbar intervertebral disc
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722.71–722.73
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Intervertebral disc disorder with myelopathy
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722.81–722.83
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Postlaminectomy syndrome (cervical, thoracic, lumbar region)
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723.1
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Cervicalgia
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724.00–724.03
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Spinal stenosis, other than cervical
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724.1
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Pain in thoracic spine
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724.2
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Lumbago
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733.13
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Pathologic fracture of vertebrae
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738.4
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Acquired spondylolisthesis
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805.00–805.08
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Cervical fracture, closed
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805.2
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Dorsal (thoracic) fracture, closed
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805.4
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Lumbar fracture, closed
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- Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
- Preprocedural evaluation leading to suspicion of the presence of facet joint pathology must be explicitly documented in the patient’s medical record along with postprocedural conclusions.
- Procedures performed will be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD.
- A diagnostic block can be repeated once, at any given level, at least one week (preferably 2 weeks) after the first block. If repeated, strong consideration should be given to utilizing administration of an anesthetic of different duration of action. (This helps confirm the validity of the diagnostic facet block, and may reduce the incidence of false positive responses due to placebo effect).
- Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.
Therapeutic Phase
- Medicare will not cover/provide payment for CPT codes 64490 and 64493 (with or without the 50 modifier) more than five (5) times in a year. This practice is never medically reasonable or necessary.
- Procedures performed will be limited to three (3) levels (whether unilateral or bilateral) for each anatomical region as defined in this LCD.
- Medicare does not expect patients to routinely undergo repeat treatment at the same anatomic region at less than 90-day intervals.
- Medicare does not expect all patients in a provider’s practice to present with pain in both anatomical regions (cervicothoracic and lumbosacral). Therefore the routine performance of facet joint/medial branch block (both diagnostic and therapeutic) to both regions may prompt a pre-payment review.
- Routinely exceeding the above parameters, by utilizing the procedure codes on the same beneficiary in unusual patterns may result in pre-payment review.
- Other interventional pain management procedures done on the same day as paravertebral facet joint blocks should be rare. In certain circumstances a patient may present with both facet and sacroiliac problems. In this case, it is appropriate to perform both facet injections and SI injection at the same session assuming that these are therapeutic injections and that prior diagnostic injections (blocks) have demonstrated that both structures contribute to pain generation. The medical record must clearly support both procedures. Medicare recognizes that this is not common and will monitor the frequency with which these codes are combined. Multiple procedure modifiers will apply to intraarticular sacroiliac injection.
Medial Branch Blocks
Lumbar Spine: Each facet joint is innervated by the medial branch of two consecutive spinal nerve roots, one medial branch from the superior aspect of the joint and one from the inferior aspect of the joint. Each medial branch runs from the facet joint and hugs around the superior articulating process, where it is covered by the mamillo-accessory ligament, trackingto the intervertebral foramen where it enters the dorsal rami of its respective spinal nerve root on its way up to the brain To perform the procedure, place the fluoroscope in the AP position, tilted if necessary in a cephalad tocaudad motion to “square up” the endplates of the vertebral bodies (Fig. 20-5). Patients with prominentlordosis may require a significant tilt of the fluoroscope. Then put the fluoroscope in the oblique position, at an approximate 25- to 30-degree angle toward the left or right side depending on which side is painful.
Using a metal marker and a felt-tip marking pen, an “X” is placed on the skin where the superior articulating process and transverse process meet at the level above and below the facet joint to be blocked (Fig. 20-9). If the pedicle was a clock face the intended target would be 10 O’clock for the left side and 2 O’clock for the right side. This is often described as the “eye of the Scotty Dog”; this is the path of the medial branch nerve.
The medial branch that innervates the S1 articulating process takes a slightly different route, crossing the ala of the sacrum (Fig. 20-10). The golden rule is that you need to block one more medial branch than the number of facet joints you are blocking—for example, if a procedure involves blocking the medial branches that innervate the L3/L4 facet joint, it is necessary to block two medial branches for this one facet joint. Another example, if you are blocking three facet joints you need to block four medial branches. Contiguous facet joints are blocked in clinical practice—let us say that the L3/ L4, L4/L5, and L5/S1 facet joints on the right are to be blocked. In this case you need to block the following nerves.
* The medial branch that innervates the L3 portion of the L3/L4 joint.
* The medial branch that innervates both the L4 portion of the L3/L4 facet joint and L4 portion of the L4/L5 facet joint.
* The medial branch that innervates both the L5 portion of the L4/L5 facet joint and L5 portion of the L5/S1 facet joint.
* The medial branch that innervates the S1 portion of the L5/S1 facet joint (Fig. 20-11).
At the sites, an “X” is marked on the skin and subcutaneous tissue is anesthetized with 2% lidocaine using a 1.5-in, 25-gauge needle. After the skin and subcutaneous tissue are anesthetized, a 3.5-in (5 in for larger patients), 22-gauge spinal needle is placed through the “X” in a perpendicular fashion to the skin and parallel to the fluoroscope. The needle is advanced until it touches bone in the path of the intendes medial branches.
Cervical Spine: For the cervical spine the anatomy is different: The medial branches curve around “the waist” of the articular pillar. This is where access is possible (Fig. 20-12). The cervical medial branches are bound by fasciae, which hold them against the articular pillar. The cervical facet joints extend from C2/C3 to C7/T1. The same preparatory steps are performed as for a lumbar medial branch nerve block. Rather than obliquing the camera, the medial branch nerves are accessed using an AP view. The needle is advanced until bone contact is made at the 0.5% bupivacaine per medial branch: For example, if three facet joints are to be blocked (four medial branches), 6 mL of 0.5% bupivacaine is drawn up into a single syringe and divided equally over the four medial branches. The needles are then removed and a bandage placed. In the recovery room, the preoperative pain score is compared with the postoperative score to see if the cervical facet joints blocked are indeed the pain generator.
Radiofrequency Ablation of the Medial Branches of the spinal nerve Roots
The science behind RF is an electric field is established around the needle tip. This field oscillates with alternating RF current causing movement of ions. This movement of ions creates friction in the tissue surrounding the catheter tip producing heat. Which causes ablation of the medial branch of the spinal nerve root. Cells become damaged at 45°C. At temperatures 60°C to 100°C, there is induction of protein coagulation leading to cell death. Standard ablation settings are 80°C for 60 seconds. RF machines can be programmed with the physicians preferred settings for sensory testing, motor testing, and ablation temperature and duration.
anesthetization, a 3.5-in, 22-gauge, Teflon-coated RF needle with a 10-mm exposed tip (Fig. 20-15; the RF needle comes in a straight- or curved-tip form—the curved tip is often easier to guide) is placed through the “X” in a perpendicular fashion to the skin and parallel to the fluoroscope. A 5-in needle may be required in larger patients. The needle is advanced until it touches bone in the path of the medial branch of the spinal nerve root. Repeat this step for the predetermined medial branches.
Once all RF needles are in position, check their location using both sensory and motor stimulations. Electrical stimulation at 50 hz should produce sensory stimulation of the intended medial branches if the tips of the needles are properly placed. To perform sensory testing the stylet of the RF needle is removed and the RF probe is placed into the needle (Fig. 20-16). The jack from the RF cable is connected to the RF machine. The RF machine is able to send a small amount of electrical stimulation to the tip of the needle. The machine is set to sensory testing and the operator slowly increase the sensory impulse up to 50 hz. If the needle is placed correctly the patient will feel a small tapping or buzzing sensation at the targeted facet joint as the medial branch is stimulated.
If the needle sits to close to the spinal nerve root, the patient will feel a shooting sensation down the leg. After proper sensory stimulation is confirmed, motor stimulation is next checked. Motor stimulation confirms a safe distance from the unintended motor fibers of the spinal nerve root. The RF machine is set to motor testing and the operator slowly increase the motor impulse up to 2 hz. Motor stimulation at 2 hz should evoke contraction of the ipsilateral paraspinal muscles with out limb contraction. Small lumbar multifidus muscles which are paraspinal in location receivemotor innervation from the medial branches. With proper motor stimulation contraction of the lumbar paraspinal muscles are seen. This is normal indicating proper needle placement. However, if the needle tip is too close to the spinal nerve root leg contraction is seen.
In this case reposition the needle until proper motor stimulation is achieved. Destruction of the medial branch nerve does not cause clinically consequential lumbar weakness. Once needle placement is properly confirmed via both fluoroscopy and electrical stimulation, remove the RF probes and anesthetize the medial branch nerves using a local anesthetic. The local anesthetic is drawn up in a single syringe. I use 1.5 mL of 0.5% bupivacaine per medial branch nerve. For example, for blocking the facet joints (four medial branch nerves), 6 mL of 0.5% bupivacaine are drawn up into a single syringe and divided equally over the four medial branches. The area is anesthetized so that this is painless for the patient
Cervical Spine: For the cervical spine, the medial branches of the cervical spinal nerves curve around “the waist” of the articular pillar; this is where they are accessed. The cervical medial branches are bound by fasciae that hold them against the articular pillar. A Teflon-coated RF needle with a 5-mm exposed tip is used rather than the 10-mm exposed tip in the lumbar spine. The same safety checkpoints and ablation protocol used for the lumbar spine are applicable for the cervical spine
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