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The Facts on Facet Joint Injections

April 2021

Coding and billing for facet joint injections has been a point of confusion. There have been questions on how to determine the number of units to report (do you count levels or nerves?), on the criteria to progress from a diagnostic to a therapeutic procedure, on if/when to progress to ablation and on the level and duration of relief that must be achieved. This Timely Topic will inform its readers on the results of a recent audit by the Health and Human Services Office of Inspector General (HHS OIG) and an updated Local Coverage Determination (LCD) developed and adopted by all the Medicare Administrative Contractors (MACs)

In February 2021, the HHS OIG posted the results of its audit on Noridian’s payments for facet joint injections. Based on its review, the HHS OIG estimated that this one Medicare Administrative Contractor (MAC) improperly paid $4.2M to physicians for these services in Jurisdiction E during the audit period which covered CY 2016 through 2018. 

The report provides the following examples of non-compliance with Medicare requirements: 

  • Spinal Levels: Facet-Joint Injections Did Not Comply With Requirements Related to Spinal Levels (e.g. physician billed for 3 levels of spine where documentation only indicated 2 levels of spine)
  • Pain: Facet-Joint Injections Did Not Comply With Requirements Related to Indications of Pain (e.g. Beneficiaries did not have a history of at least 3 months of moderate to severe pain with functional impairment)
  • Therapeutic Injections: Facet-Joint Injections Did Not Comply With Requirements for Therapeutic Injections (e.g. therapeutic injections were repeated, but the previous injections did not result in significant pain relief for at least 3 months)
  • Diagnostic Injections: Facet-Joint Injections Did Not Comply With Requirements for Diagnostic Injections
  • Limited Coverage Requirements: A Facet-Joint Injection Did Not Comply With Limitation-of-Coverage Requirements

The OIG recommends that Noridian take steps to recover the improper payments and to provide training to physicians and billing staff on Medicare’s requirements to bill for facet joint injections. 

A summary of the report is available HERE. The full report is available HERE.  

The Medicare LCD in effect during the audit period was strict and complex. In March 2021, the MACs across all Medicare jurisdictions released an updated LCD on Facet Joint Injections for Pain Management. The new LCD became effective on April 25, 2021 and can be viewed HERE.

The LCD addresses coverage indications, limitations and medical necessity considerations for diagnostic and therapeutic facet joint injections, facet joint denervation, and facet cyst aspiration/rupture  as described by CPT® codes:

  • 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
  • 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; 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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)
  • 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
  • 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
  • 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
  • 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
  • 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

It also provides links to two articles with more information: 

It is important that physicians and coding/billing professionals from practices that perform and report these procedures educate themselves on this new LCD and the associated additional articles. Doing so will help avoid delays and denials of claims for these procedures.