CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP036

Paravertebral Facet Injection Procedure Billing & Coding Policy

This policy defines billing, coding, documentation, and modifier use for paravertebral (facet) joint injection procedures performed by professional providers and facilities under Blue Cross Blue Shield of Illinois.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyParavertebral Facet Injection Procedure Billing & Coding Policy

Policy CodePolicy CPCP036

Change TypeNo material changes

Effective DateNov 6, 2024

Next Review DateN/A

Key ActionObtain prior authorization and provide supporting documentation when requested to determine benefit coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 64490-64495Primary and add-on facet injection codes discussed

0213T-0218TCategory III (ultrasound-guided) codes listed

Documentation listMinimum documentation elements required

Modifier -50 guidanceBilateral billing rules

Coverage and Medical Necessity

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Coverage and billing criteria

Coverage determination and medical necessity referrals

ALL of the following

Medical necessity determination
- Refer to Medical Policy SUR702.015 (Facet Joint Injections) and applicable Plan medical policies or Carelon Medical Benefits Management clinical guidelines for medical necessity criteria.
Documentation and supporting information
- The plan may request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.
- Documentation must substantiate the diagnosis, day-of-service care, relevant medical history including prior failed interventions, physical exam, and diagnostic test results (as applicable).
Billing and code reporting rules
- Image guidance (fluoroscopy or CT) and contrast injection are included in CPT codes 64490–64495 and should not be reported separately (e.g., do not separately report 77001–77003, 77012).
- Primary facet injection codes (64490, 64493) should not be reported more than once per day; add-on codes (64491–64492, 64494–64495) are reported in conjunction for additional levels per coding guidance.
- When a bilateral procedure is reported, use modifier -50 and report quantity as one for the bilateral service; do not append RT/LT or use modifier -59 on bilateral add-on codes (per plan examples and billing rules).
Coverage limitations and benefit determination
- Inclusion of codes in this billing guidance does not guarantee reimbursement; benefits are member-specific and subject to the member's plan documents and applicable laws.
- Medical necessity and benefit coverage decisions are determined by separate medical policies and member plan documents (see SUR702.015).

Procedures may require prior authorization; providers should obtain prior authorization when required by the member's plan and be prepared to provide requested supporting documentation to substantiate medical necessity.

CPT and Category III Codes

Facet joint injection CPT codesCPTCovered

64490	Injection paravertebral facet joint cervical/thoracic 1 level (primary)
64491	Injection paravertebral facet joint cervical/thoracic 2 levels (add-on)
64492	Injection paravertebral facet joint cervical/thoracic 3 levels (add-on)
64493	Injection paravertebral facet joint lumbar/sacral 1 level (primary)
64494	Injection paravertebral facet joint lumbar/sacral 2 levels (add-on)
64495	Injection paravertebral facet joint lumbar/sacral 3 levels (add-on)

Category III ultrasound-guided codesCPT

0213T-0218T

Category III codes for paravertebral injections performed under ultrasound guidance

Per-day reporting

Per-day reporting for primary codesCPT 64490 and 64493 (primary codes) should not be reported more than once per day; report once per level, per side.

Add-on code useCPT 64491, 64492 (cervical/thoracic add-ons) and 64494, 64495 (lumbar/sacral add-ons) are add-on codes to be used in conjunction with the corresponding primary code for additional levels.

Reporting frequency for add-onsAdd-on codes should be reported once per day per their appropriate usage when used with the primary code for additional levels.

Multiple needle placementsCPT 64490-64495 should be reported once per level, per side regardless of the number of needle placements required.

Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization and documentation requests

Procedures may require prior authorization. The plan reserves the right to request supporting documentation; benefit coverage is determined by the member-specific benefit plan and applicable laws. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Obtain prior authorization when required by the member's plan before performing facet joint injections.
Be prepared to provide supporting documentation upon request to substantiate medical necessity and coding.
Verify member-specific benefits and any applicable legal mandates, since inclusion of a code does not guarantee reimbursement.

Key Definitions

Facet joint — definition

Facet (zygapophysial) joint level definitionA facet joint, or zygapophysial joint level, refers to the facet joint or the two medial branch nerves that innervate that facet joint.

Procedural purposeFacet joint block procedures are used for diagnosis and treatment of chronic cervical/thoracic and lumbar back pain originating from the paravertebral facet joints.

Image guidance requirementFacet joint interventions must be performed under fluoroscopic or CT guidance; image guidance and any contrast injection are inclusive components of CPT 64490-64495.

Ultrasound-guided Category III codesCPT Category III codes 0213T-0218T represent paravertebral injections performed under ultrasound guidance and should not have separate ultrasound guidance codes reported.

Image guidance — definition and inclusion

Image guidance inclusionImage guidance (fluoroscopy or CT) and any contrast injection are inclusive components of CPT 64490-64495; do not report separate fluoroscopic/CT guidance codes (e.g., 77001-77003, 77012).

Ultrasound guidance for Category III codesCPT Category III codes 0213T-0218T are performed under ultrasound guidance; providers should not report separate ultrasound guidance codes (e.g., 76942) when these descriptors include guidance.

Purpose of guidanceImaging guidance is used to assure accurate needle placement for the injection.