CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP036

Paravertebral Facet Injection Procedure Coding & Billing Policy

This policy defines coding, billing, documentation, and reimbursement guidance for paravertebral (facet) joint injection procedures for providers and facilities contracting with Blue Cross Blue Shield New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyParavertebral Facet Injection Procedure Coding & Billing Policy

Policy CodePolicy CPCP036

Change TypeNo material changes

Effective DateDec 28, 2022

Next Review Date

Key ActionProcedures may require prior authorization; submit supporting documentation and verify member-specific benefit coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495Primary CPT codes addressed

0213T-0218TCategory III codes listed

InclusiveImage guidance

Required listDocumentation elements

2022-12-28Plan effective date

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Coverage and billing criteria

Coverage and medical necessity are determined by referenced medical policies and AIM Specialty Health; providers should refer to the Plan's Medical Policies for clinical criteria and to member-specific benefits for coverage determinations.

Refer to Plan Medical Policies and AIM Specialty Health Clinical Guidelines for medical necessity criteria

See Plan Medical Policies and AIM Specialty Health for when fluoroscopic-guided facet injections may be considered medically necessary.

Image guidance and contrast are integral to CPT 64490-64495; do not separately bill guidance codes (e.g., 77001-77003, 77012) when included

Report primary CPT codes (64490-64495) only once per level, per side; use add-on codes (64491/64492/64494/64495) per descriptor and bill bilateral add-on codes with modifier -50 and quantity = 1

Procedures may require prior authorization; benefit coverage is determined by the member-specific benefit plan and applicable laws

Documentation and supporting records may be requested; the plan reserves the right to review claims on a case-by-case basis and denial may occur if coding/billing policies are not followed

Inclusion of a code in this document does not guarantee reimbursement; claims remain subject to plan, contract, and coding edits

Primary, Related Codes and Reporting Rules

Covered CPT CodesCPTCovered

64490	Injection, paravertebral facet joint; cervical or thoracic, single level (primary)
64491	Injection, paravertebral facet joint; cervical or thoracic, each additional level (add-on)
64492	Injection, paravertebral facet joint; cervical or thoracic, third level (add-on)
64493	Injection, paravertebral facet joint; lumbar or sacral, single level (primary)
64494	Injection, paravertebral facet joint; lumbar or sacral, second level (add-on)
64495	Injection, paravertebral facet joint; lumbar or sacral, third level (add-on)
0213T	Category III: Injection, paravertebral facet joint with ultrasound guidance, cervical
0214T	Category III: Injection, paravertebral facet joint with ultrasound guidance, cervical
0215T	Category III: Injection, paravertebral facet joint with ultrasound guidance, thoracic
0216T	Category III: Injection, paravertebral facet joint with ultrasound guidance, lumbar/sacral

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Per-day reporting — guidance that primary codes (64490, 64493) are not reported more than once per day per level and add-on code reporting rules

Per-day reportingPrimary codes 64490 and 64493 should not be reported more than once per day per level. Add-on codes (64491, 64492, 64494, 64495) are reported in conjunction with their primary codes and also should not be reported more than once per day.

Bilateral reportingWhen injections are performed bilaterally at the same level, report the primary injection code (64490 or 64493) with modifier -50. Bilateral add-on codes (64491, 64492, 64494, 64495) should be billed with modifier -50 and the number of services reported as one (1). Do not append RT, LT or -59 to these bilateral add-on codes.

Guidance inclusiveImage guidance and any injection of contrast are inclusive components of CPT codes 64490-64495. Do not separately report guidance codes such as 77001-77003 or 77012 when fluoroscopic or CT guidance is included in the primary code descriptor. Similarly, do not report ultrasound guidance code 76942 for Category III codes 0213T-0218T when ultrasound guidance is included.

Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization and Documentation Requests

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 and may review claims on a case-by-case basis; failure to provide requested documentation or to follow coding/billing guidance may impact claims processing and reimbursement.

Obtain prior authorization when required by the member's benefit plan before performing the procedure.
Maintain and provide supporting documentation as requested to substantiate medical necessity and coding.
Be aware that inclusion of a code in the policy does not guarantee reimbursement; claims are subject to plan, contract, and code edits and case-by-case review.

Key Definitions

Chronic pain

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

Clinical contextFacet joint interventions may be used for management of chronic cervical, thoracic, and back pain originating from paravertebral facet joints.

Implication for documentationRecords should reflect duration of pain (≥12 weeks) when chronic pain is the indication for facet interventions.

Facet joint / Z-joint

Anatomic definitionFacet joint (zygapophysial joint) is a diarthrodial joint in the spinal column forming the articulation of posterior elements of adjacent vertebrae.

Laterality per levelThere are two facet joints at each spinal level — a right and a left joint (bilateral superior and inferior articular surfaces).

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

Medial Branch Block (MBB)

Procedure definitionMedial Branch Block (MBB) is the placement of local anesthetic, with or without a corticosteroid, near the medial branch nerve that supplies the sensory innervation to a specific facet joint.

TargetMBB targets the medial branch nerve (a dorsal ramus branch) that supplies the facet joint.

Relation to facet injectionFacet injections may be performed into the joint capsule or along the medial branch nerves; MBB is the perineural injection adjacent to the medial branch.