Anesthesiologists and pain specialists need to pay special attention to billing and documenting facet joint injections as this area is prone to errors.

1. Documenting and
Billing for Facet
Joint Injections
Anesthesiologists and pain specialists need to pay
special attention to billing and documenting facet
joint injections as this area is prone to errors.
Outsource Strategies International
8596 E. 101st Street, Suite H
Tulsa, OK 74133

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Located at the back of the spine, facet joints connect the vertebrae together and are
one of the most common and significant sources of back and neck pain. Facet joint
blocks or injections are performed in an office-based procedure suite or in an
ambulatory surgical center. Anesthesiologists and pain specialists need to pay
special attention to billing and documenting facet joint injections as this is a
potential high risk area for “fraud and abuse”, according to a
www.anesthesiallc.com report. Outsourcing medical billing and coding to an expert
is the best option to report facet joint injections correctly. Their teams keep track of
constantly changing codes and guidelines and can help physicians submit accurate
claims.
Facet Joint Syndrome
Healthy facets joints have cartilage, are lubricated with synovial fluid, and are covered
by a joint capsule. The vertebrae glide smoothly against each other. Facet joint
syndrome is caused by degenerative changes to these joints caused by aging, pressure
overload of the joints, and injury. This narrows the space between each vertebra
and eventually the cartilage breaks down and causes the bones to rub against each
other. Bone spurs may form and as they grow larger, will extend into and narrow the
spinal canal. This condition is called spinal stenosis.
The main symptoms of facet joint syndrome are pain, soreness and stiffness.
Prolonged periods of inactivity like sitting or standing too long can cause pain.
Changing positions often improves pain. pain management options include
medication, joint injections, nerve blocks, physical therapy, and nerve ablations.
Patients with chronic symptoms may require surgery to repair the joint.

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CPT Codes for Facet Joint Injections
A minimally-invasive procedure, the facet joint block or injection involves using
fluoroscopy or CT imaging to inject a local anesthetic and/or medication into the
facet joint to numb the joint provide pain relief. There are 6 CPT codes for facet
joint injections and medial branch nerve block procedures:
64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), cervical or thoracic, single level
+64491 …second level (list separately in addition to code for primary procedure)
+64492 …third and any additional level(s) (list separately in addition to code for
primary procedure)
64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), lumbar or sacral; single level
+64494 …second level (list separately in addition to code for primary procedure)
+64495 …third and any additional level(s) (list separately in addition to code for
primary procedure)
Facet Joint Injections – Reporting Guidelines
 CPT 64490-64495 should be reported once per level, per side, regardless of
the number of needle placements that are required. For e.g., report:
- If injections are performed on both sides of one vertebral level, report
CPT codes 64490 or 64493 with modifier 50 Bilateral procedure.

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- If a second level is injected bilaterally, add-on code (64491 or 64494)
should be reported with modifier 50.
 Imaging guidance is bundled into facet joint injections and many of the other
pain procedures that anesthesiologists perform. Therefore, when reporting
facet joint codes, image guidance cannot be billed separately.
 If ultrasound guidance is used for fluoroscopy and computed axial
tomography, CPT guidelines state that the facet joint injection should be
reported using 0213T-0218T Injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with ultrasound guidance….
 If no imaging is used, CPT codes 20552-20553 Injection(s); single or
multiple trigger point(s)…. should be reported.
New Imaging Guidance Instructions in CPT 2019
Providers need to pay attention to new instructions specific to imaging guidance in
CPT 2019 (www.asahq.org). The new CPT instruction is: “When imaging
guidance or imaging supervision and interpretation is included in a surgical
procedure, guidelines for image documentation and report, included in the
guidelines for Radiology (Including Nuclear Medicine and Diagnostic
Ultrasound), will apply.”
The referenced text from the Radiology Guidelines is as follows: “Imaging may be
required during the performance of certain procedures or certain imaging
procedures may require surgical procedures to access the imaged area. Many
services include image guidance, and imaging guidance is not separately

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reportable when it is included in the base service. The CPT code set typically
defines in descriptors and/or guidelines when imaging guidance is included. When
imaging is not included in a surgical procedure or procedure from the Medicine
section, image guidance codes or codes labeled “radiological supervision and
interpretation” (RS&I) may be reported for the portion of the service that requires
imaging. All imaging guidance codes require: (1) image documentation in the
patient record and (2) description of imaging guidance in the procedure report.
All RS&I codes require: (1) image documentation in the patient’s permanent
record and (2) a procedure report or separate imaging report that includes written
documentation of interpretive findings of information contained in the images and
radiologic supervision of the service.”
Take Care to Avoid Common Billing Errors
As the HHS Office of the Inspector General (OIG) has found coding and billing
errors in claims for facet joint injections, they come in for
intense scrutiny. One common error identified by the HSS Office
involved bilateral injections, where a bilateral injection was reported by listing the
base code for the first side to code for primary procedure and the add-on code for
the second side at the same level (www.aapc.com).
Providers should also be knowledgeable about Medicare carrier policies (Local
Coverage Determinations) and applicable private payer policies on facet joint and
other pain medicine injections. Common documentation errors to watch out for
include:
- Missing documentation or documentation lacking a description of the
procedure performed

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- Not including cervical or lumbar levels, and other details
- Documentation does not support the diagnosis and demonstrate medical
necessity
Partnering with an experienced medical billing and coding service provider can
help providers ensure clean claim submission and receive appropriate
reimbursement for facet joint injections.