Billing and Coding: Facet Joint Interventions for Pain Management A57787

Article Information

General Information

Article ID

A57787

Article Title

Billing and Coding: Facet Joint Interventions for Pain Management

Article Type

Billing and Coding

Original Effective Date

10/03/2018

Revision Effective Date

01/05/2026

Revision Ending Date

N/A

Retirement Date

N/A

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

• CMS IOM Publication 100-04, Medicare Claims Processing Manual,

  • Chapter 12, Section 40.7 Claims for Bilateral Surgeries

  • Chapter 13, Section 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures, Section 20 Payment Conditions for Radiology Services, and Section 30 Computerized Axial Tomography (CT) Procedures

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• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33930, Facet Joint Interventions for Pain Management. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

General Guidelines for Claims submitted to Part A or Part B MAC or Ambulatory Surgery Center (ASC):

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.

Coding Guidance: Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

This article applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).

Diagnostic and Therapeutic Procedures:

CPT Codes 64490, 64491, 64492, 64493, 64494, 64495 describe the introduction/ injection of a diagnostic or therapeutic agent into the paravertebral facet joint or into the nerves that innervate that joint by level.

Facet joints are paired joints with 1 pair at each vertebral level (i.e., there are 2 facet joints per level, 1 on the right side and 1 on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint [intraarticular] injection [IA], a medial branch block injection [MBB], or the medial branch radiofrequency ablation [neurotomy]) in 1 session. A bilateral intervention is still considered a single level facet intervention.

When determining a level, count the number of facet joints injected not the number of nerves injected. Therefore, if multiple nerves of the same facet joint are injected it would be considered as a single level. The add-on codes are reported when second, third, or additional levels are injected during the same session.

When the procedure is performed bilaterally at the same level, report 1 unit of the primary code with modifier -50. When the procedure is performed unilaterally, it must be reported as 1 unit of the primary code with modifier -RT or -LT. If the appropriate laterality modifier is not appended to the claim line, the claim line will be rejected.

When the procedure is performed bilaterally at 1 level and unilaterally at a different level report 1 unit of the primary procedure. If the procedure is performed unilaterally at different levels report 1 unit of the primary procedure and the appropriate add-on code.

Regions:

As defined by the Current Procedural Terminology (CPT) Professional edition code book, there are 2 distinct anatomic spinal regions for paravertebral facet injections: cervical /thoracic (codes 64490, 64491) and lumbar/sacral (codes 64493, 64494).

Levels:

CPT code 64490 (cervical or thoracic) or CPT code 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or computed tomography [CT]). Procedures performed under ultrasound guidance are not covered.

CPT code 64491 or 64494 describes a second level which must be reported separately in addition to the code for the primary procedure. CPT code 64491 must be reported in conjunction with CPT code 64490 and CPT code 64494 should be reported in conjunction with CPT code 64490 or 64493.

CPT code 64492 or 64495 describes a third and additional levels and must be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. CPT code 64492 must be reported in conjunction with CPT code 64490/64491 and CPT code 64495 must be reported in conjunction with CPT code 64493/64494.

For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once.For bilateral paravertebral facet injection of the T12-L1 and L1 – L2 levels or nerves innervating that joint, use 64490 with modifier 50 and 64494 with modifier 50.

Laterality:

Bilateral paravertebral facet injection procedures must be reported with modifier -50. Unilateral paravertebral facet injection procedures must be reported with laterality modifier -RT or -LT. If the appropriate laterality modifier is not appended to the claim line, the claim line will be rejected.

One to 2 levels, either unilateral or bilateral, are allowed per session per spine region (i.e., 2 unilateral or 2 bilateral levels per session).

For services performed in the ASC, physicians must continue to use modifier -50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.

KX modifier requirements:

The KX modifier must be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the 2 initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.

Chemodenervation of nerve:

CPT codes 64633, 64634, 64635, and 64636 are reported per joint, not per nerve. Although 2 nerves innervate each facet joint, only 1 unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2024).

Each unilateral or bilateral intervention at any level must be reported as 1 unit, with unilateral intervention signified by appending a laterality modifier (-RT or -LT) and bilateral intervention signified by appending the modifier -50.

Region:

An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT codes 64633 and 64634) or lumbar/sacral (CPT codes 64635 and 64636) per the AMA CPT Manual.

For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use CPT code 64633.

Levels:

CPT code 64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT).

Use CPT code 64634 or 64636 to report each additional facet joint at a different vertebral level in the same spinal region.

CPT code 64634 must be used in conjunction with CPT code 64633 and CPT code 64636 must be used in conjunction with CPT code 64635.

Laterality:

For bilateral procedures, report modifier -50 on each line in which the intervention was of a bilateral nature.

For services performed in the ASC, physicians must continue to use modifier -50. Only the ASC Facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.

Non-thermal facet joint denervation (including chemical, low grade thermal energy [<80 degrees Celsius] or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services must be reported with CPT code 64999. CPT code 64999 is non-covered when used to report non-thermal facet joint denervation.

If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Benefit Policy Manual Chapter 16: Section 180.

Consistent with the LCD, the use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is not reasonable and necessary for facet injections. Claims reporting anesthesia with facet injections will be denied.

Consistent with the LCD, the use of moderate sedation or MAC for radiofrequency ablation (RFA) or cyst aspiration/rupture may be considered if medical necessity is clearly established. Documentation must explain the medical necessity for sedation and frequent reporting of these services together may trigger focused medical review.

Utilization Parameters

Note: A session is defined as all procedures (i.e., MBB, IA, facet cyst ruptures, and destruction by a neurolytic agent [e.g., RFA]) performed on the same date of service.

CPT codes 64490 through 64494 will be limited to no more than 4 sessions, per region, per rolling 12 months.

CPT codes 64490 through 64494 with the KX modifier will be limited to no more than 4 sessions, per region, per rolling 12 months.

CPT codes 64633 through 64636 will be limited to no more than 2 sessions, per region, per rolling 12 months.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

4. The patient’s medical record must include but is not limited to:

5. The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit

   • Relevant medical history

   • Results of pertinent tests/procedures

   • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

6. Documentation of why the patient is not a candidate for RFA must be submitted for therapeutic injection procedures.

7. The scales used to assess the measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Score (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function.

Coding Information

CPT/HCPCS Codes

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Group 1

(8 Codes)

Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.The following CPT codes need to be listed separately in addition to a code for the primary procedure: 64491, 64494, 64634, and 64636.

Group 1 Codes

Code	Description
64490	Inj paravert f jnt c/t 1 lev
64491	Inj paravert f jnt c/t 2 lev
64493	Inj paravert f jnt l/s 1 lev
64494	Inj paravert f jnt l/s 2 lev
64633	Destroy cerv/thor facet jnt
64634	Destroy c/th facet jnt addl
64635	Destroy lumb/sac facet jnt
64636	Destroy l/s facet jnt addl

Group 2

(12 Codes)

Group 2 Paragraph

Note: CPT code 64999 is non-covered when used to report non-thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), or any form of pulsed radiofrequency.Note: When reporting CPT code 64999 ensure that the description of the service is included on the claim.Consistent with the LCD, the following CPT/HCPCS codes do not support medical necessity and are non-covered.*This is not an inclusive list of non-covered codes.*Note: CPT code 64492 or 64495 describes a third and additional levels and must be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. CPT code 64492 must be reported in conjunction with CPT code 64490/64491 and CPT code 64495 must be reported in conjunction with 64493/64494. CPT codes 64492 and 64495 will only be covered if sufficient documentation of medical necessity is present.

Group 2 Codes

Code	Description
64492	Inj paravert f jnt c/t 3 lev
64495	Inj paravert f jnt l/s 3 lev
0213T	Njx paravert w/us cer/thor
0214T	Njx paravert w/us cer/thor
0215T	Njx paravert w/us cer/thor
0216T	Njx paravert w/us lumb/sac
0217T	Njx paravert w/us lumb/sac
0218T	Njx paravert w/us lumb/sac
0219T	Plmt post facet implt cerv
0220T	Plmt post facet implt thor
0221T	Plmt post facet implt lumb
0222T	Plmt post facet implt addl

CPT/HCPCS Modifiers

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Group 1

(4 Codes)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
50	BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
KX	REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
LT	LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT	RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(20 Codes)

Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 64490, 64491, 64493, 64494, 64633, 64634, 64635, and 64636.

Group 1 Codes

Code	Description
M47.812	Spondylosis without myelopathy or radiculopathy, cervical region
M47.813	Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814	Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815	Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816	Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817	Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.892	Other spondylosis, cervical region
M47.893	Other spondylosis, cervicothoracic region
M47.894	Other spondylosis, thoracic region
M47.895	Other spondylosis, thoracolumbar region
M47.896	Other spondylosis, lumbar region
M47.897	Other spondylosis, lumbosacral region
M48.12	Ankylosing hyperostosis [Forestier], cervical region
M48.13	Ankylosing hyperostosis [Forestier], cervicothoracic region
M48.14	Ankylosing hyperostosis [Forestier], thoracic region
M48.15	Ankylosing hyperostosis [Forestier], thoracolumbar region
M48.16	Ankylosing hyperostosis [Forestier], lumbar region
M48.17	Ankylosing hyperostosis [Forestier], lumbosacral region
M71.30*	Other bursal cyst, unspecified site
M71.38*	Other bursal cyst, other site

Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM Codes M71.30 or M71.38 are allowed for facet cyst rupture procedures only.

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)

Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes

Code	Description
XX000	Not Applicable

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code	Description
999x	Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation
01/05/2026	R10	Article revised and published on 4/9/2026 effective for dates of service on and after 1/05/2026. Coding guidance regarding laterality modifiers was added to the article. The word ‘should’ was replaced with ‘must’ to provide clarification throughout the article.
09/19/2024	R9	Article revised and published on 09/19/2024 in response to an inquiry. This revision was to add the code 64490 to the following sentence: CPT code 64491 should be reported in conjunction with CPT code 64490 and CPT code 64494 should be reported in conjunction with CPT code 64493. Also, under Diagnostic and Therapeutic procedures section the following information was added: For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once.For bilateral paravertebral facet injection of the T12-L1 and L1 – L2 levels or nerves innervating that joint, use 64490 with modifier 50 and 64494 with modifier 50.
08/11/2024	R8	Article posted for notice on 06/27/2024 to become effective on 08/11/2024.Draft article posted on 02/15/2024.
11/30/2023	R7	Article revised and published on 11/30/2023 effective for dates of service on and after 04/25/2021 in response to an inquiry. The language addressing use of CPT code 64999 for facet cyst aspiration/rupture has been removed. The following CPT code has been removed from the ICD-10 Group 1 Paragraph: 64999.
01/01/2023	R6	Article revised and published on 02/09/2023 effective for dates of service on and after 01/01/2023. The ‘Diagnostic and Therapeutic Procedures’ section of the article was revised to add coding guidance for injections involving T12 – L1 and L1 -L2 levels.
01/01/2023	R5	Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 64999 in Group 1 and Group 2 Codes.
04/25/2021	R4	Article revised and published on 05/27/2021 effective for dates of service on and after 04/25/2021. The “Diagnostic and Therapeutic Procedures:” and Neurolytic Destruction Procedures (Radiofrequency Ablation):” sections of the article were revised to clarify coding guidance for the add-on CPT codes 64491/64494 (second level) and 64634/ 64636 (each additional) when billing bilaterally. Also, the “Internet-Only Manuals” section of the article was updated to include Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.7 Claims for Bilateral Surgeries.
04/25/2021	R3	Article revised and published on 04/22/2021 effective for dates of service on and after 04/25/2021. This revision was to add clarifying language to the paragraph under the “KX modifier requirements:” section of the Article. Also, minor formatting change made throughout the coding section.
04/25/2021	R2	Final Article published on 03/11/2021 effective for dates of service on and after 04/25/2021.  10/29/2020 - Draft Article posted.
10/01/2020	R1	Revision Number: 1Publication: September 2020 ConnectionLCR B2020-013 Explanation of Revision: Based on CR 11845 (Annual 2021 ICD-10-CM Update) the Billing and Coding Article was revised to add ICD-10-CM code M25.59 to “ICD-10 Codes that Support Medical Necessity/ Group 1 Codes:”. The effective date of this revision is for dates of service on or after October 1, 2020.

Associated Documents

Related Local Coverage Documents

Articles

DA57787 - Billing and Coding: Facet Joint Interventions for Pain Management (MCD Archive Site)

A59829 - Response to Comments: Facet Joint Interventions for Pain Management

LCDs

L33930 - Facet Joint Interventions for Pain Management

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