CPT Code and Description

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

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

64492 or 64495 describes a third and additional levels and should 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. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.

CODE – 64493
DESCRIPTION – INJ PARAVERT F JNT l/s 1 lev

Note: 64492 or 64495 describes a third and additional levels and should 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. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494. Codes 64492 and 64495 will only be covered upon appeal if sufficient documentation of medical necessity is present.

Medicare is establishing the following limited coverage for CPT/HCPCS codes: 64490, 64491, 64493, 64494, 64633, 64634, 64635, and 64636.

Diagnostic or therapeutic injections/nerve blocks may be required for the management of chronic pain. It may take multiple nerve blocks targeting different anatomic structures to establish the etiology of the chronic pain in a given patient. It is standard medical practice to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first set of procedures fails to produce the desired effect or to rule out the diagnosis, the provider should then proceed to the next logical test or treatment indicated. For the purpose of this paravertebral facet joint block LCD, an anatomic region is defined per CPT as cervical/thoracic (64490, 64491, 64492) or lumbar/sacral (64493, 64494, 64495).
Fluoroscopic or Computed Tomography (CT) image guidance and localization are required for the performance of paravertebral facet joint injections described by CPT codes 64490, 64491, 64492, 64493, 64494, and 64495. For paravertebral spinal nerves and branches? image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of CPT codes 64490, 64491, 64492, 64493, 64494, and 64495.

Group 1 Codes:
64490 INJ PARAVERT F JNT c/t 1 lev
64491 INJ PARAVERT F JNT c/t 2 lev
64492 INJ PARAVERT F JNT c/t 3 lev
64493 INJ PARAVERT F JNT l/s 1 lev
64494 INJ PARAVERT F JNT l/s 2 lev
64495 INJ PARAVERT F JNT l/s 3 lev

Therapeutic phase

Medicare will not cover/provide payment for CPT codes 64490 and 64493 (with or without the 50 modifier) more than five (5) times in a year. This practice is never medically reasonable or necessary

CPT Codes Required Clinical Information

Facet Joint and Medial Branch Block Injections for Spinal Pain
64490
64493

For initial injection, medical notes documenting the following, when applicable:
Diagnosis
History of the medical condition(s) requiring treatment, including duration of pain and findings suggesting facet joint origin
Documentation of signs and symptoms; include onset, duration, and frequency
Physical exam, including presence of findings on facet loading maneuvers
Relevant medical and surgical history; including history of previous spinal procedures/interventions, including but not limited to previous facet injection and previous surgery(ies)
Treatments tried, failed, or contraindicated; include the dates, duration of treatment, and reason for discontinuation
Reports of all recent imaging studies and applicable diagnostics.

Physician treatment plan, including:
o Location of proposed injection (side and level)
o Injected anesthetic volume plan
o Plan for use of ultrasound guidance
o Plan for radiofrequency joint denervation/ablation procedure
o Severity of pain on a 1-10 scale after conservative treatment (e.g., pharmacotherapy, exercises)
For second injection, in addition to the above, also include the response to initial facet injection, including:
Level, side, and date of initial and second injection
Duration of the effect

Coverage Rationale

The following are proven and medically necessary:
An initial diagnostic Facet Joint Injection/Medial Branch Block to determine facet joint origin when all of the following criteria are met:
o Pain is exacerbated by facet loading maneuvers on physical examination (e.g., hyperextension, rotation); and
o Clinically significant improvement has not occurred (the pain remains at a 3 or more on a 1-10 pain scale) after a minimum of four weeks of conservative care (including but not limited to pharmacotherapy, exercise, or physical therapy); and
o Clinical findings and imaging studies suggest no other cause of the pain (e.g., spinal stenosis with neurogenic claudication, disc herniation with radicular pain, infection, tumor, fracture, pain related to prior surgery); and o The spinal motion segment is not fused; and
o A radiofrequency joint denervation/ablation procedure is being considered
A second Facet Joint Injection/Medial Branch Block performed to confirm the validity of the clinical response to the initial
Facet Joint Injection, when all of the following criteria are met:
o Administered at the same level and side as the initial block; and
o The initial diagnostic Facet Joint Injection produced a positive response as demonstrated when all the following criteria
are met:
o For at least the expected minimum duration of the effect of the local anesthetic; and
o Functional improvement that is specific to the individual with demonstrable improvement in the physical functions previously limited by the facetogenic pain and
o A radiofrequency joint denervation/ablation procedure is being considered

Facet Joint Injections/Medial Branch Blocks are unproven and not medically necessary due to insufficient evidence of efficacy:
If radiofrequency ablation procedure not considered as treatment option at the requested level(s)
For treating spinal pain, after diagnostic injections have been completed
After two Facet Injections/Medial Branch Blocks at the same level and same side (this is considered therapeutic rather than diagnostic)
Therapeutic Facet Joint Injections and/or Facet Nerve Block (i.e., Medial Branch Block) for treating chronic spinal pain
For a second Facet Joint Injection/Medial Branch Block if the initial injection did not confirm the joint as the source of pain
In the presence of untreated Radiculopathy at the same level as the intended diagnostic injection (with the exception of Radiculopathy caused by a facet joint synovial cyst)
If injection of volume of local anesthetics exceeds 0.5ml for Medial Branch Blocks When performed under ultrasound guidance