FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION
Contractor’s Determination Number
First Coast Service Options, Inc.
09202 – Puerto Rico
Paravertebral Facet Joint Blocks
Because of the diagnostic nature of facet blocks, precise localization is necessary. Therefore, it is expected that use of the facet codes (CPT 64490-64495) would require radiologic localization (i.e., fluoroscopy). Blocks performed without the use of fluoroscopy are considered not medically necessary. Imaging guidance (fluoroscopy CT) and any injection of contrast are inclusive components of 64490-64495 and not paid separately.
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. The 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. Likewise, 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.
(current) use of anticoagulants) should be used only as a supplementary code in
addition to the primary diagnosis. This code should be reported when the use of
anticoagulants has been temporarily discontinued to facilitate multiple
interventional therapeutic modalities (e.g., facet joint blocks, trigger point
injections, lumbar sympathetic blocks) for pain management.
2 - Added verbiage to clarify the “Coding Guidelines” section of the LCD that fluoroscopy is an inclusive component of CPT Codes 64490-64495 and not paid separately. The revision is effective for claims processed on or after 10/04/2011 for dates of service on or after 01/01/2010.
1 - Annual 2010 HCPCS Update. Deleted CPT codes 64470, 64472, 64475 and 64476. Added CPT codes 64490, 64491, 64492, 64493, 64494 and 64495. Deleted instructions regarding billing codes for image guidance in addition to procedure codes for paravertebral injections (64490-64495). New 2010 HCPCS codes include image guidance. Contractor Determination Number was changed to 64490 The effective date of this revision is based on date of service.
Document formatted: 09/21/2011 (SSE/et)