CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP036

Paravertebral Facet Injection Procedure Billing & Coding Policy

Billing, coding, documentation, and modifier guidance for paravertebral (facet) joint injection procedures performed by professional providers and facilities under Blue Cross Blue Shield of New Mexico plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyParavertebral Facet Injection Procedure Billing & Coding Policy

Policy CodePolicy CPCP036

Change TypeNo material change

Effective DateNov 18, 2024

Next Review Date

Key ActionObtain prior authorization when required and submit documentation supporting diagnosis, day-of-service care, and relevant medical history to substantiate medical necessity and reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495Primary CPT codes addressed

0213T-0218TCategory III CPT codes listed

CPCP036Policy identifier

11/18/2024Plan effective

InclusiveImaging guidance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Billing Rules

Coverage criteria and billing rules

Coverage and reimbursement are subject to member benefit plan, medical policy criteria, documentation, and coding rules. The plan may request supporting documentation and reserves discretion in interpretation.

Required documentation must substantiate diagnosis, day-of-service care, relevant medical history (including prior tried and failed interventions), physical examination, and results of diagnostic tests or procedures.

Image guidance (fluoroscopic or CT) and any injection of contrast are inclusive components of CPT codes 64490-64495; do not report separate guidance codes (e.g., 77001-77003, 77012) when guidance is inherent in the code descriptor.

Report CPT codes 64490-64495 once per anatomic level, per side; codes should be reported only once per level per side regardless of the number of needle placements.

Procedures may require prior authorization; coverage and medical necessity determinations are made according to the member-specific benefit plan and applicable medical policies and clinical guidelines.

Claims are subject to coding and billing rules, code edit protocols, provider contract terms, medical policies, and claims review; failure to adhere may affect claims processing and reimbursement.

CPT and Category III Codes; Reporting Limits

Covered CPT Codes - Facet joint primary and add-onCPTCovered

64490	INJ PARAVERT F JNT C/T 1 LEV
64491	INJ PARAVERT F JNT C/T 2 LEV (add-on)
64492	INJ PARAVERT F JNT C/T 3 LEV (add-on)
64493	INJ PARAVERT F JNT L/S 1 LEV
64494	INJ PARAVERT F JNT L/S 2 LEV (add-on)
64495	INJ PARAVERT F JNT L/S 3 LEV (add-on)

Covered Category III CPT Codes - Ultrasound-guided paravertebral injectionsCPTCovered

0213T	NJX PARAVERT W/US CER/THOR
0214T	NJX PARAVERT W/US CER/THOR
0215T	NJX PARAVERT W/US CER/THOR
0216T	NJX PARAVERT W/US LUMB/SAC
0217T	NJX PARAVERT W/US LUMB/SAC
0218T	NJX PARAVERT W/US LUMB/SAC

Per‑day reporting limits — single‑day frequency restrictions for primary and add‑on codes

Primary per-day limitCPT 64490 and 64493 — each should not be reported more than once per day (primary codes).

Add-on codes per-day useCPT 64491, 64492, 64494, 64495 — add-on codes used in conjunction with the appropriate primary code and each should not be reported more than once per day.

Per-level/side reportingCPT 64490-64495 should be reported once per vertebral level, per side regardless of number of needle placements.

Prior Authorization, Guidance, and Billing Rules

Note

Prior authorization, imaging guidance inclusivity, and modifier -50 billing rules

Procedures may require prior authorization and benefit coverage is determined by the member-specific benefit plan and any applicable laws. Image guidance (fluoroscopic or CT) and any injection of contrast are inclusive components of CPT codes 64490–64495; do not report separate guidance codes (e.g., 77001–77003, 77012) when guidance is inherent. For bilateral procedures, report bilateral services with modifier -50 as one unit; do not append RT/LT or modifier -59 to bilateral add-on codes (64491, 64492, 64494, 64495). The plan reserves the right to request supporting documentation and failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Prior authorization may be required; verify member-specific plan coverage and applicable laws.
Do not separately report guidance codes (77001–77003, 77012) when fluoroscopic/CT guidance and contrast are included in CPT 64490–64495.
Report CPT 64490–64495 once per level, per side; primary codes (64490, 64493) should not be reported more than once per day.
For unilateral injections at one level, report the primary code with RT or LT; add-on codes for additional levels are reported with RT or LT as appropriate.
For bilateral injections, bill the primary or add-on codes with modifier -50 and report quantity as one; appending RT, LT, or -59 to bilateral add-on codes is not appropriate and may lead to denial.
The plan may request supporting documentation; noncompliance with coding and billing policies may affect reimbursement.

Key Terms and Modifiers

Facet joint — definition/term (zygapophysial level)

TermFacet joint (zygapophysial) level — refers to the facet joint or the two medial branch nerves that innervate that facet joint.

Clinical contextFacet joint block procedures are used for diagnostic and/or therapeutic pain management for chronic cervical, thoracic, and back pain stemming from paravertebral facet joints.

Imaging guidanceImage guidance (fluoroscopic or CT) is used to assure accurate needle placement for injections at the facet joint level.

Modifier -50 — bilateral procedure billing guidance; single line/unit when appropriate

Billing when bilateralUse modifier -50 for bilateral procedures (report the service on one line with one unit) when the code descriptor is not already bilateral; report the primary code with -50 for bilateral injections.

Add-on bilateral billingBilateral billing of add-on codes (64491, 64492, 64494, 64495) must use modifier -50 and be reported as one service; appending RT/LT or -59 to these bilateral add-on codes is inappropriate and will be denied.

Unilateral reportingWhen performed unilaterally, report the primary code (64490 or 64493) with RT or LT; add-on codes for additional levels unilaterally should also use RT or LT.