When reporting facet joint and facet joint nerve injections, CPT codes 64470 to 64476 are out, in favor of codes 64490 to 64495. Here's a rundown of the new spinal block codes for 2010:

• 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, plus the primary procedure's code.

Coding and billing tips
Here are tips for using these new codes to ensure proper reimbursement.

One code per level and side. Report only 1 facet injection code at a specified level and side injected regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level. For example, code a left-sided L4-L5 intra-articular facet injection performed with a single needle puncture as 64493. You'd also code injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint as 64493, even though you performed 2 separate injections.

Three-level injection coding limit. You can't report 64492 or 64495 more than once per day. This is troublesome, because codes 64492 and 64495 are used to report the "third and any additional level(s);" the inability to report either code more than once per day means that you can't repeat these codes when patients have more than 3 levels blocked. (This coding limitation didn't exist with deleted codes 64470 to 64476.) For example, let's consider fluoroscopic-guided bilateral lumbar facet injections/intra-articular zygapophyseal joint injections at L2-3, L3-4, L4-5 and L5-S1. If L5-S1 were the fourth level you injected, you wouldn't code that per the 2010 guidelines because you'd need to repeat code 64495. Instead, you'd use codes 64493-50, 64494-50 and 64495-50.

Fourth and subsequent levels. If the third-party payor allows it, report and bill the fourth and subsequent levels injected using the "Units" field 24G on the CMS-1500 claim form or the "Service Units" field 46 on the UB-04 claim form. If some payors don't let you report multiple units for the fourth and subsequent level injections, then consider appending a non-covered modifier —GY next to code 64492 or 64495 for those levels that are not covered, but for which you want to reflect your cost or charges on the claim. Modifier —GY lets you separately code and bill all levels injected while communicating to the payor that no payment is expected. The description for modifier —GY is: Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.

Bilateral facet joint injections. To bill for the bilateral fourth and greater level facet joint injections, some payors may let you report 2 units of service next to code 64495 since the code can't be reported more than once per day.

Medically Unlikely Edits. Medicare uses Medically Unlikely Edits (MUE) for some HCPCS/CPT codes to identify the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE, however, including codes 64490 to 64495. Your Medicare contractor may accept multiple units of service for codes 64492 and 64495. For current MUE guidelines, contact your Medicare contractor or see www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp.

Multiple region injection. The 2010 CPT code book does not prohibit the reporting of codes 64490, 64491, 64493 and 64494 more than once per day. It appears that you can repeat these codes if multiple spinal regions are blocked and there is a need to repeat these codes.

For example, let's say you performed fluoroscopic guided bilateral facet injections/intra-articular zygapophyseal joint injections at C2-3, C3-4, C4-5, C5-6, C6-7, C7-T1, T1-T2 and T2-3. That's 5 levels of cervical facet joint injections and 3 levels of thoracic facet joint injections. For C2-3, C3-4, C4-5, C5-6, C6-7, you'd use 64490-50, 64491-50 and 64492-50 times 3 units. For C7-T1, T1-2, T2-3, you'd use 64490-50, 64491-50 and 64492-50. The thoracic region was injected in addition to the cervical region, and both regions are classified in codes 64490 to 64492, so you'd need to repeat codes 64490 to 64492.

Image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of 64490 to 64495, so don't report fluoroscopy code 77003 in addition to these codes. For bilateral facet injection procedures, use modifier -50. For injection of the T12-L1 joint, or nerves innervating that joint, use 64493.