CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP036

Paravertebral Facet Injection Procedure Coding & Billing Policy

Defines coding, billing, documentation, and reimbursement guidance for paravertebral facet joint and medial branch injection procedures for providers submitting claims to BCBSOK. Applies to in-network and out-of-network professional providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyParavertebral Facet Injection Procedure Coding & Billing Policy

Policy CodePolicy CPCP036

Change TypeNo material change

Effective DateNov 2, 2021

Next Review Date

Key ActionEnsure facet interventions are performed under fluoroscopic or CT guidance and submit required documentation to support medical necessity and billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495Primary and add-on CPT codes addressed

0213T-0218TCategory III ultrasound codes noted

RequiredDocumentation

RequiredImaging guidance

Coverage Determinations and Billing Rules

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Coverage Criteria and Billing Rules

Coverage and payment are determined by member-specific benefit plans and applicable medical policy criteria; claims must meet documentation, coding, and billing rules to be reimbursed.

Imaging guidance requirement: 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 (do not report separate guidance codes such as 77001-77003 or 77012).

Documentation requirement: Medical record must substantiate the suspected diagnosis and include care rendered on the date of service, relevant medical history (e.g., prior tried and failed interventions), physical examination, and results of diagnostic tests and/or procedures.

Per-level reporting and bilateral billing rules: CPT codes 64490-64495 should be reported once per level, per side; primary codes (64490 or 64493) reported for the first level and add-on codes (64491/64492/64494/64495) used for additional levels. If an injection is performed bilaterally at a level report the primary code with modifier -50; bilateral add-on codes (64491, 64492, 64494, 64495) must be billed with modifier -50 and reported as one (1) service. Appending RT, LT or modifier -59 to these bilateral add-on codes is inappropriate and will be denied.

Billing rule — guidance codes and ultrasound: Do not report separate image guidance codes when guidance is included in the procedure code descriptor. Inclusion of Category III ultrasound codes does not guarantee reimbursement and guidance codes should not be reported when guidance is integral to the CPT code.

Administrative and prior authorization: Procedures may require prior authorization; benefit coverage is determined by the member-specific benefit plan. The plan reserves the right to request supporting documentation and may review claims on a case-by-case basis; inclusion of a code does not guarantee reimbursement.

Reference guidance: Providers should refer to Medical Policy SUR702.015 and AIM Specialty Health clinical guidelines (and other related medical policies and CMS) for medical necessity criteria, provider qualifications, limitations, indications, and frequency criteria.

Procedure Codes and Reporting Rules

Facet joint 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 codesCPT

0213T-0218T

Category III ultrasound-guided paravertebral injections (cervical/thoracic and lumbar/sacral)

Per-level reporting rules

Primary vs add-on codesPrimary facet injection codes (64490 for cervical/thoracic, 64493 for lumbar/sacral) are reported once per level per side; add-on codes (64491/64492 for C/T; 64494/64495 for L/S) are used for additional levels and must be reported in conjunction with the appropriate primary code.

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

Bilateral codingIf an injection is performed bilaterally at a single level, report the primary code with modifier -50; bilateral add-on codes (64491, 64492, 64494, 64495) must be billed with modifier -50 and reported as one unit of service.

Modifier prohibitionsDo not append RT, LT, or modifier -59 to bilateral add-on codes (64491, 64492, 64494, 64495); such appending is inappropriate and will result in denial.

Image guidance inclusivityFluoroscopic or CT guidance and any injection of contrast are inclusive to CPT codes 64490-64495; do not separately report guidance codes (e.g., 77001-77003, 77012) when included in the procedure descriptor.

Authorization, Documentation & Denial Risks

Prior Authorization

Prior Authorization, Documentation Requests, and Member Benefit Determination

Procedures may require prior authorization; benefit coverage is determined by the member-specific benefit plan. BCBSOK reserves the right to request supporting documentation and will review claims on a case-by-case basis. Providers should refer to Plan Medical Policies and AIM Specialty Health guidelines for medical necessity determinations.

Benefit coverage determined by member-specific plan and applicable laws.
BCBSOK may request supporting documentation; claims may be reviewed case-by-case.
Refer to Medical Policies and AIM Specialty Health Clinical Guidelines for medical necessity.

Denial Risk

Avoid Reporting Separate Guidance and Incorrect Modifier Use (Denial Risk)

Do not report separate image guidance codes when fluoroscopic or CT guidance is included in the CPT procedure descriptor; guidance and contrast are inclusive to CPT codes 64490-64495. Bilateral add-on codes must be billed with modifier -50 as one unit; appending RT, LT, or modifier -59 to bilateral add-on codes is inappropriate and will be denied.

Do not report guidance codes such as 77001-77003 or 77012 when guidance is included in 64490-64495.
CPT codes 64491, 64492, 64494, 64495 billed bilaterally must use modifier -50 and be reported with one (1) unit.
Appending RT, LT, or -59 to bilateral add-on codes is inappropriate and will result in denial.

Key Terms

Chronic pain

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

Clinical relevanceUsed as the temporal threshold for considering facet joint or medial branch interventions for diagnostic or therapeutic management.

Documentation implicationMedical records should document duration of symptoms to substantiate chronic pain (>=12 weeks) when justifying interventions.

Facet joint

AnatomyFacet joint (zygapophysial joint) is a diarthrodial joint of the posterior elements of adjacent vertebrae, bilateral at each spinal level.

Level notationFacet joints are described by the vertebral level that forms them (e.g., C4-5 or L2-3); there are right and left facet joints at each level.

Alternate namesAlso called zygapophysial joint or Z-joint.

Facet injection (facet block)

Procedure definitionFacet injection (facet block) is the injection of local anesthetic, with possible corticosteroid, into the facet joint capsule or along the medial branch nerves supplying the facet joints (C2-3 to L5-S1).

PurposePerformed for diagnostic and/or therapeutic management of facet-mediated spinal pain.

Substances usedLocal anesthetic and possibly a corticosteroid; contrast may be used and image guidance is required per billing rules.

Medial Branch Block (MBB)

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

TargetTargets the dorsal ramus/medial branch nerve to provide diagnostic information about facet joint pain.

Relation to facet injectionMBB is distinct from intra-articular facet injection; it places injectate near the medial branch rather than into the joint capsule.