The term "facet joint injection" may describe either a nerve block (CPT 64470 to 64476) or a more extensive nerve destruction (CPT 64622 to 64627). To confuse matters further, CPT defines both nerve blocks and nerve destructions as occurring per "level," although the definition of "level" varies between the two types of procedures. Let's set things straight.

One level equals two nerves
When reporting nerve blocks, focus on the "joint" — the area between adjacent nerves — that the physician targets. Therefore, one nerve block "level" will actually involve two nerves.

• Example 1. If the physician provides diagnostic nerve blocks for C2, C3 and C4, he is addressing three nerves, but only two levels (the joint at C2/C3 and the joint at C3/C4).
• Example 2. Similarly, if the physician wishes to block the nerves from L1 to L4, he is addressing four nerves (L1, L2, L3 and L4), but only three levels (L1/L2, L2/L3 and L3/L4).

Under CPT rules, you may report one unit of 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) for the initial level the physician addresses in either the cervical or thoracic region. For each additional cervical or thoracic level that the physician targets beyond the first, you may apply +64472 (???cervical or thoracic, each additional level [list separately in addition to code for primary procedure]).

In our first example, you'd report 64470 for the initial injection (at level C2/C3) and one unit of 64472 for the additional injection (at level C3/C4).

Similarly, you'd apply 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) for the first lumbar or sacral level the physician injects and +64476 (???lumbar or sacral, each additional level [list separately in addition to code for primary procedure]) for each additional lumbar or sacral level.

In our second example, you'd report 64475 for the initial lumbar level (L1/L2) and 64476 x 2 for the two additional levels (L2/L3 and L3/L4).

Per level, not per injection
Note that you should apply nerve block codes 64470 to 64476 per level, as already described, rather than per injection. This is an important distinction because the physician may provide more than one injection per level. Let's say the surgeon provides a left-side L4/L5 intra-articular injection via a single needle puncture, or he may administer two separate injections to the medial branch nerves supplying the L4/L5 facet joint. In either case, you'd report a single unit of 64475 because the physician is blocking a single level.

Anatomic research has found that the L5/S1 facet joint level receives innervation from three nerves (the L4, L5 and S1 paravertebral facet joint nerves). If your physician blocks each of these nerves with a separate injection, you should nevertheless report one unit of 64475 because, once again, the physician has addressed just a single level (L5/S1).

Bilateral procedures
Be aware, however, that nerve block codes 64470 to 64476 describe unilateral procedures. That is, the code descriptors assume that the physician targets the joint on either the left or right side. If the physician addresses both the left and right side at the same level, CPT and CMS guidelines let you report a bilateral procedure.

In a hospital outpatient setting, you may apply modifier-50 (Bilateral procedure) or modifiers -LT (Left side) and -RT (Right side), as appropriate, to describe bilateral nerve blocks. For example, if the physician targets the C3/C4 and C4/C5 joints on both the left and right, you may report either 64470-50, 64472-50 or — for those payors that prefer the anatomical modifiers — 64470-LT, 64470-RT and 64472-LT, 64472-RT.

CMS warns that in an ASC, modifier -50 "will not be recognized for payment purposes and may result in incorrect payment." Instead, when reporting bilateral nerve blocks to Medicare for POS 24 (Ambulatory surgical center), follow CMS instructions and report bilateral procedures "as a single unit on two separate lines or with ???2' in the ???units' field on one line." To report bilateral C3/C4 and C4/C5 nerve blocks for Medicare, for example, you'd report 64470 x 2 on one line and 64472 x 2 on a second line.

When claiming nerve destruction, count the actual number of nerves the physician injects. For codes 64622 to 64627, therefore, one "level" does, indeed, equal one nerve.

If the physician documents, for instance, "C4 and C5 facet joint nerve destruction," you'd report 64626 (Destruction by neurolytic agent, paravertebral facet join nerve; cervical or thoracic, single level) for the first nerve/level (C4) and 64627 (???cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) for the additional nerve/level (C5).

Count only the number of nerves the physician injects, not individual injections. Multiple injections to the same nerve count as a single level.

Additionally, nerve destruction codes, like nerve block codes, describe unilateral procedures. You may report bilateral procedures using modifier -50 or modifiers -LT and -RT as appropriate. ASCs billing Medicare for bilateral procedures must report multiple code units, as discussed above.

If he destroys and blocks
If the physician provides facet joint injections for both nerve blocking and destruction at the same location on the same date of service, report only the destruction procedure, according to CPT and payor instructions. "When destruction of the facet joint nerve follows blocking of the same nerve, only the codes for nerve destruction should be billed," instructs a typical local coverage determination for facet joint injections from National Government Services, a Part B carrier in New York State.

Let's say the physician provides a diagnostic nerve block for nerves at L2, L3 and L4, followed shortly thereafter by injection of a neurolytic agent to the same nerves. The block occurs at two levels (L2/L3 and L3/L4), while the destruction occurs on three levels (L2, L3, L4). Because destruction includes blocking, however, you'd report only the nerve destruction, using 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) for the first level (L2) and +64623 (???lumbar or sacral, each additional level [list separately in addition to code for primary procedure]) x 2 for additional levels L3 and L4.

If the physician uses fluoroscopic guidance for needle placement with either nerve block or nerve destruction procedures, you may separately report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction). Report this code only once per session, regardless of the number of injections the physician administers.

Note that although you may report 77003 for fluoroscopy in the ASC, CMS assigns this code an "N1" payment indicator. This means fluoroscopic guidance is an integral or "packaged service/item" for which Medicare will make no separate payment.

Whether you're reporting nerve blocks or nerve destruction, be sure to link your procedure code(s) to an accurate diagnosis to the highest possible level of specificity allowed by the available documentation. Finally, realize that many payers tightly control the maximum number of nerve block or nerve destruction codes you may report within a specified time period. Some large Medicare carriers may deny medical necessity for "facet joint nerve block injections on more than three spinal levels on the same day."