CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP036

Paravertebral Facet Injection Procedure Coding & Billing Policy

Defines coding, billing, and documentation expectations for paravertebral/zygapophysial (facet) joint injection procedures for providers billing Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyParavertebral Facet Injection Procedure Coding & Billing Policy

Policy CodePolicy CPCP036

Change TypeNo material change

Effective DateJan 3, 2023

Next Review DateN/A

Key ActionProcedures may require prior authorization and the plan may request supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64490-64495Primary and add-on CPT codes for paravertebral facet injections referenced

0213T-0218TCategory III (ultrasound) CPT codes listed

Documentation listMinimum documentation elements required

RequiredImaging guidance required

Coverage Criteria and Billing Rules

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Coverage criteria and billing rules

Coverage and medical necessity are determined by the member-specific benefit plan and referenced medical policies; imaging guidance requirements and billing rules are summarized below.

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 fluoroscopic/CT guidance codes (e.g., 77001-77003, 77012) when guidance is included in the CPT descriptor for 64490-64495.

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

Billing for bilateral same-level injections: report the primary injection code (64490 or 64493) with modifier -50 and one unit.

When a second level is injected bilaterally, report the appropriate add-on code (64491 or 64494) with modifier -50 and report one unit; bilateral billing for add-on codes 64491, 64492, 64494, 64495 must use modifier -50 and be reported as one service. Appending RT, LT or modifier -59 to these bilateral add-on codes is not appropriate and will be denied.

Procedures may require prior authorization; benefit coverage is determined by the member-specific benefit plan and any applicable laws. The plan reserves the right to request supporting documentation and review claims on a case-by-case basis.

Inclusion of a CPT code in this policy does not guarantee reimbursement; providers should refer to the Plan Medical Policies and AIM Specialty Health Clinical Guidelines on the Plan website for medical necessity criteria for facet joint injections performed under fluoroscopy.

CPT and Category III Codes; Billing Conventions

CPT paravertebral facet injection codesCPTCovered

64490	Injection paravertebral facet, cervical/thoracic; 1 level
64491	Injection paravertebral facet, cervical/thoracic; 2 levels (add-on)
64492	Injection paravertebral facet, cervical/thoracic; 3 levels (add-on)
64493	Injection paravertebral facet, lumbar/sacral; 1 level
64494	Injection paravertebral facet, lumbar/sacral; 2 levels (add-on)
64495	Injection paravertebral facet, lumbar/sacral; 3 levels (add-on)

Per-day and bilateral reporting notesmixed

No codes listed

Category III (ultrasound) codesCPT

0213T-0218T

Category III paravertebral injections performed under ultrasound guidance

Per-day and bilateral reporting rules for paravertebral facet injections

Primary code reporting frequencyCPT 64490 and 64493 should be reported once per level, per side regardless of number of needle placements.

Add-on code usageUse add-on codes (64491, 64492, 64494, 64495) for additional levels; add-on codes follow the once-per-level, per-side rule.

Bilateral billing modifierReport bilateral same-level injections with modifier -50 and report one (1) unit for the line item (do not report separate RT/LT).

Bilateral add-on code guidanceWhen billing bilateral add-on codes (64491, 64492, 64494, 64495) bill with modifier -50 and one unit; do not append RT, LT, or modifier -59 to these codes.

Guidance codes not separately billableDo not report separate fluoroscopic/CT guidance codes (e.g., 77001-77003, 77012) because image guidance and contrast are inclusive to CPT 64490-64495.

Prior Authorization and Documentation Requests

Prior Authorization

Prior authorization and documentation requests

Procedures may require prior authorization. Benefit coverage for services is determined by the member-specific benefit plan and any applicable laws; inclusion of a code in this policy does not guarantee reimbursement. The plan reserves the right to request supporting documentation and to review claims on a case-by-case basis.

Obtain prior authorization when required by the member's benefit plan before performing facet joint interventions.
Be prepared to submit supporting documentation upon request to substantiate medical necessity and coding.
Inclusion of a CPT code in this policy is not a guarantee of payment; verify member benefits and applicable laws.

Key Definitions

Chronic pain

DefinitionChronic pain: pain persisting greater than or equal to 12 weeks after onset.

ContextUsed to distinguish long-standing spinal pain for which facet interventions may be considered.

Documentation implicationClinical records should document duration meeting the ≥12-week threshold to support chronic pain diagnosis.

Facet joint (zygapophysial joint)

Anatomical definitionFacet joint (zygapophysial joint): a diarthrodial joint in the spinal column formed by articulation of posterior elements of adjacent vertebrae; two (right and left) at each spinal level.

NomenclatureFacet joints are designated by the vertebral levels that form them (e.g., C4-5, L2-3).

FunctionProduces articulation of posterior elements and provides bilateral superior and inferior articular surfaces at each level.

Facet injection (facet block)

DefinitionFacet injection (facet block): injection of local anesthetic and possibly a 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 spinal pain originating from facet joints.

Technique noteProcedures are performed with imaging guidance (fluoroscopy or CT) to ensure accurate needle placement; image guidance is inclusive to the CPT codes for these services.

Medial Branch Block (MBB)

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

Target nervesThe medial branch is a dorsal ramus branch supplying the facet joint sensory innervation.

Clinical useUsed diagnostically to determine if facet joints are the pain source and may guide further therapeutic interventions.