CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP036

Paravertebral Facet Injection Procedure Coding & Billing Policy

Coding and billing rules for paravertebral (facet) joint injection procedures affecting professional providers and facilities participating with BCBSNM; describes appropriate CPT/Category III coding, modifiers, documentation and reimbursement considerations.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyParavertebral Facet Injection Procedure Coding & Billing Policy

Policy CodePolicy CPCP036

Change TypeNo material change

Effective DateNov 3, 2023

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting documentation as required, since procedures may require prior authorization and coverage is member-specific.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495Primary and add-on CPT codes addressed

0213T-0217TCategory III CPT codes listed

1.0Policy version

2023-11-03Plan effective date

Coverage and Reimbursement Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyParavertebral Facet Injection Procedure Coding & Billing Policy

Policy CodePolicy CPCP036

Change TypeNo material change

Effective DateNov 3, 2023

Next Review DateN/A

Key ActionObtain prior authorization and submit supporting documentation as required, since procedures may require prior authorization and coverage is member-specific.

SourceLink

On This Page

ALL of the following

Benefit and legal determination
- Benefit coverage for the service is determined by the member-specific benefit plan and any applicable laws that may require coverage for a specific service.
Medical necessity and policy alignment
- Services performed under fluoroscopic or CT guidance should be consistent with the Plan's Medical Policies and Carelon Medical Benefits Management Health Clinical Guidelines; refer to Medical Policies on the Provider tab of the Plan website for criteria on medical necessity.
Documentation requirements
- Documentation must be submitted and include substantiation of the diagnosis; care rendered on the day of service; the member's relevant medical history (for example, prior tried and failed interventions); physical examination; and results of diagnostic tests and/or procedures.
Coding and billing compliance
- Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance; image guidance and any injection of contrast are inclusive components of CPT codes 64490-64495 and should not be billed separately.
- CPT codes 64490-64495 should be reported once per level, per side; primary codes (64490 or 64493) reported once per level per side and add-on codes (64491, 64492, 64494, 64495) reported per additional level; bilateral procedures should use modifier -50 as described in the coding rules.
Prior authorization and plan rights
- Procedures may require prior authorization; the plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

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Procedure Codes and Reporting Rules

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 facet injection codesCPT

0213T	Paravertebral injection with ultrasound guidance, cervical/thoracic (Category III)
0214T	Paravertebral injection with ultrasound guidance, cervical/thoracic (Category III)
0215T	Paravertebral injection with ultrasound guidance, cervical/thoracic (Category III)
0216T	Paravertebral injection with ultrasound guidance, lumbar/sacral (Category III)
0217T	Paravertebral injection with ultrasound guidance, lumbar/sacral (Category III)

Per-level reporting

Primary vs add-on reportingPrimary codes (64490 for cervical/thoracic; 64493 for lumbar/sacral) are reported once per level per side; add-on codes (64491-64492 and 64494-64495) are reported for additional levels in conjunction with the appropriate primary code.

Bilateral reportingIf an injection is performed bilaterally at one level, report the primary code with modifier -50; if a second level is injected bilaterally, report the add-on code with modifier -50.

Units and modifiers for bilateral add-onsBilateral procedures billed with add-on codes (64491, 64492, 64494, 64495) must be billed with modifier -50 and the number of services reported as one; appending RT/LT or -59 to these add-on codes is not appropriate and will be denied.

Provider Billing, Authorization, and Documentation

Note

Prior authorization and supporting documentation may be required

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

Procedures may require prior authorization; verify member benefits and obtain authorization when required.
The plan may request supporting documentation to substantiate the claim; provide documentation as requested to avoid processing or reimbursement impacts.

Key Definitions

Chronic pain

DefinitionChronic pain is pain persisting greater than or equal to 12 weeks after the onset of pain.

ContextUsed to distinguish long-standing pain conditions that may be managed with facet joint interventions.

Temporal thresholdThreshold for classification: >= 12 weeks from onset.

Facet joint (Z-joint)

Anatomical definitionFacet joint (zygapophysial joint or Z-joint) is a diarthrodial joint in the spinal column forming articulation of posterior elements between adjacent vertebrae.

Location and lateralityThere are bilateral superior and inferior articular surfaces at each spinal level (right and left facet joints for each level).

NomenclatureFacet joints are identified/classified by the specific vertebral level that forms them (e.g., C4-5 or L2-3).

Medial Branch Block (MBB)

Procedure descriptionMedial Branch Block (MBB) is the placement of local anesthetic and possibly a corticosteroid near the medial branch nerve that supplies sensory innervation to a specific facet joint.

TargetTargets the medial branch of the dorsal ramus which provides sensory innervation to the facet joint.

Relation to facet injectionFacet injection (facet block) can describe injections into the facet joint capsule or along the medial branch nerves from C2-3 to L5-S1; MBB is the medial branch nerve-focused technique.