CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP036

Paravertebral Facet Injection Procedure Billing & Coding Policy

Defines billing, coding, documentation and modifier use for paravertebral (facet) joint injection procedures for providers and facilities covered by Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyParavertebral Facet Injection Procedure Billing & Coding Policy

Policy CodePolicy CPCP036

Change TypeNo material changes

Effective DateNov 14, 2024

Next Review DateN/A

Key ActionCheck member-specific benefits and obtain prior authorization when required before performing facet joint injection procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495, 0213T-0218TCPT/CPT III codes referenced

Image guidance inclusiveGuidance included

4 itemsDocumentation

SUR702.015Related policy

Coverage and Documentation Requirements

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 Documentation Criteria

Covered when ALL of the following documentation, coding and authorization conditions are met:

ALL of the following

Substantiation of the diagnosis (document clinical indication and target facet level).
Care rendered on the day of service (procedure note).
Relevant medical history including prior tried and failed interventions.
Physical examination findings supporting the procedure.
Results of diagnostic tests and/or procedures (e.g., imaging, diagnostic blocks) as applicable.

ALL of the following

Report CPT codes 64490-64495 once per level, per side; do not report a primary code more than once per level per side regardless of number of needle placements (per-level reporting).per level, per side
Image guidance (fluoroscopic or CT) and injection of contrast are inclusive to CPT 64490-64495; do not separately report guidance codes such as 77001-77003 or 77012 when guidance is included in the CPT descriptor.
Follow modifier guidance: for unilateral procedures report RT/LT on primary and add-on codes as appropriate; for bilateral procedures use modifier -50 on the primary (and add-on when appropriate) and report one unit of service (do not append RT/LT or modifier -59 to bilateral add-on codes).

ALL of the following

Prior authorization: Procedures may require prior authorization; confirm member-specific plan benefits and any applicable preauthorization requirements (see referenced medical policies and Carelon guidelines).
Benefit and contract precedence: If there is a conflict between this policy and a member's plan document, the plan document governs; claims remain subject to review and contract/plan language.

Procedure Codes, Reporting and Guidance

Facet joint injection CPT codesCPTCovered

64490	Injection paravertebral facet C/T 1 level (primary)
64491	Injection paravertebral facet C/T 2 level (+add-on)
64492	Injection paravertebral facet C/T 3 level (+add-on)
64493	Injection paravertebral facet L/S 1 level (primary)
64494	Injection paravertebral facet L/S 2 level (+add-on)
64495	Injection paravertebral facet L/S 3 level (+add-on)

Category III (ultrasound) codesCPT

0213T	Paravertebral injection with ultrasound guidance (cervical/thoracic)
0214T	Paravertebral injection with ultrasound guidance (cervical/thoracic)
0215T	Paravertebral injection with ultrasound guidance (cervical/thoracic)
0216T	Paravertebral injection with ultrasound guidance (lumbosacral)
0217T	Paravertebral injection with ultrasound guidance (lumbosacral)
0218T	Paravertebral injection with ultrasound guidance (lumbosacral)

Per-level reporting

Per-level reportingReport CPT codes 64490-64495 only once per vertebral level per side regardless of number of needle placements.

Add-on codes64491, 64492, 64494 and 64495 are add-on level codes and must be reported only in conjunction with the appropriate primary code for that same side/level.

Bilateral primary and add-onWhen a primary or add-on is performed bilaterally at the same level, report the appropriate code with modifier -50 and report one unit of service.

Unilateral modifier useFor unilateral injections on one side, append RT or LT to the primary (64490 or 64493) and to any add-on reported for that same side/level.

Prohibition on inappropriate modifiersDo not append RT, LT or modifier -59 to bilateral add-on codes (64491, 64492, 64494, 64495); such billing is not appropriate and claims will be denied.

Guidance inclusion

Fluoroscopic/CT guidanceFluoroscopic or CT image 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 guidance is included in the descriptor.

Ultrasound (Category III) guidanceCPT Category III codes 0213T-0218T include ultrasound guidance; do not separately report ultrasound guidance code 76942 when ultrasound guidance is included in the descriptor.

Guidance reporting ruleIf image guidance is specified in the CPT descriptor for the service, do not bill separate guidance codes for that same service.

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization and Coverage Determination

Procedures may require prior authorization. Benefit coverage for services is determined by the member-specific benefit plan and any applicable laws that may require coverage for a specific service. Providers should verify benefits and obtain any required prior authorization before scheduling services to avoid claim denials or delays. Upon request, providers are urged to submit supporting documentation to assist benefit determination and medical review.

Affected codes may vary by plan; inclusion of a code in policy does not guarantee coverage.
Prior authorization requirements and processes are defined by the member’s benefit plan and may be accessed via the Plan’s Provider website or medical management vendor.
Failure to obtain required prior authorization may result in claim denials or reduced reimbursement.

Documentation Required

Documentation Requests and Conflict Resolution

Providers are responsible for submission of accurate and complete documentation to support services billed. The plan reserves the right to request supporting documentation and to review claims for coding, medical necessity, and compliance with provider contract terms. If a conflict arises between this Clinical Payment and Coding Policy and a member’s plan document, the plan document will govern. If a conflict arises between this policy and any provider contract, the provider contract will govern. Providers should respond promptly to documentation requests; failure to provide requested information may adversely affect claim payment or adjudication.

Submit claims using valid HIPAA-approved code sets and follow industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS/NCCI edits).
Claims are subject to claim review, code edit protocols, and any software logic used by the Plan.
For disputes, the applicable provider contract and member plan documents govern resolution; BCBSOK retains discretionary authority to interpret and apply this policy as allowed by plan documents.

Terminology and Modifiers

Facet joint (zygapophysial) level — definition

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

Clinical useFacet joint block procedures are used for diagnostic or therapeutic pain management of chronic cervical, thoracic and back pain related to the paravertebral facet joints.

Imaging guidanceImaging guidance (fluoroscopy, CT, or ultrasound for Category III codes) is used to ensure accurate needle placement for the injection.

Modifier -50 — bilateral procedure reporting guidance

Meaning of -50Modifier -50 indicates a bilateral procedure performed during the same service and should be used only when the code descriptor does not already indicate bilateral.

Reporting unitsWhen using modifier -50 for bilateral services, report one (1) unit of service for the code.

ApplicabilityUse modifier -50 only for procedures performed on identical anatomical sites (both sides) during the same service.

Do not combine with RT/LT or -59Do not append RT, LT or modifier -59 to bilateral add-on codes (e.g., 64491, 64492, 64494, 64495); such billing is inappropriate and claims may be denied.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyParavertebral Facet Injection Procedure Billing & Coding Policy

Policy CodePolicy CPCP036

Change TypeNo material changes

Effective DateNov 14, 2024

Next Review DateN/A

Key ActionCheck member-specific benefits and obtain prior authorization when required before performing facet joint injection procedures.

SourceLink

On This Page