Chronic pain management treatments are among the most performed procedures. However, they are also one of the most difficult to bill. One specific area where many billers face difficulty is the proper coding of multi-level facet joint injections in the lumbar spine.
This often involves the use of CPT code 64494. That’s why we have covered this vital code in our ‘CPT Code Guides’ series. In today’s guide, our billing experts have explained what code 64494 is, when to use it, and how you can avoid denials for it.
So, let’s start.
CPT Code 64494 – Description
CPT code 64494 is defined as:
“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).”
To use code 64494 correctly, it is essential to understand in detail what the definition entails and the code’s relationship to other codes in the facet joint injection family. Let’s break down everything into simple terms.
The first thing to note is that CPT code 64494 is an “add-on” code. This means it can never be reported as a standalone service. It must always be used when another primary facet joint injection code is used, like CPT code 64493, which covers the first lumbar or sacral level.
Another point that we can deduce from the definition is that 64494 is strictly for the lumbar or sacral spine. It cannot be used for thoracic or cervical injections. Additionally, the entire procedure is performed with the help of imaging (fluoroscopy or CT). The reimbursement for imaging is bundled into code 64494, so you cannot bill it separately.
The last point worth mentioning is that CPT 64494 represents an injection for both diagnostic and therapeutic purposes. The procedure differs a bit for both. In the diagnostic scenario, the physician injects a local anesthetic, like lidocaine, into the facet joint. The patient is then monitored for changes in pain level. A positive diagnostic response typically requires at least 50% pain relief and confirms that the facet joint is the source of pain.
On the contrary, in therapeutic cases, instead of an anesthetic agent, medicines like corticosteroids are administered to relieve the pain.
Scenarios Where CPT Code 64494 is Applicable
Now that we have explained what CPT code 64494 is, let’s try to picture how to use it effectively in real-world scenarios. Here are a couple of examples:
Lumbar Spondylosis
Suppose an elderly female patient arrives at the pain management clinic with chronic lower back pain and stiffness. The discomfort has progressively worsened over several months, limiting her daily activities. Physical examination and imaging studies reveal degenerative changes in the lumbar spine consistent with spondylosis. To provide relief, the physician decides to perform paravertebral facet joint nerve blocks. The procedure involves injecting an anesthetic at the L3 level initially, followed by an additional injection at the L4 level under imaging guidance.
In this scenario, the billing department can bill the first injection via CPT code 64493 and the second injection with CPT code 64494.
Specified Dorsopathies
Suppose a 48-year-old construction worker presents with persistent lumbar pain that worsens with movement and prolonged standing. He describes localized discomfort without radiating symptoms. After conservative treatments fail, the physician recommends paravertebral facet joint injections to target inflammation and pain. The procedure begins with a nerve block at the L4 lumbar level, followed by a second injection at the L5 level to ensure comprehensive coverage.
After that, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 64493 is used for the first injection level, and CPT code 64494 is used for the second level.
Applicable Modifiers for CPT Code 64494
Using the wrong modifiers is a big reason for 64494 denials. The rules are stricter for facet joint injections when compared with other codes. The following are some modifiers that can be used with this code:
| Modifier | Description | Application |
|---|---|---|
| 50 | Bilateral Procedure | Required when injecting both right and left facet joints at the same vertebral level during a single session. |
| KX | Specified Medical Necessity | Used for all facet joint diagnostic injections. Indicates the medical necessity of additional diagnostic injections after the first two. |
| RT/LT | Right/Left Side | Used by ASC facilities for bilateral procedures (reported on separate lines instead of modifier 50). |
Source: CMS
Note: Only Ambulatory surgical centers (ASCs) can use modifiers RT and LT. Do not use them if the procedure was performed in other settings. Additionally, the use of modifier 59 is also not justified for CPT code 64494 because it is already distinct by definition as a “second-level” add-on code.
CPT Code 64494 – Billing & Reimbursement Guidelines
The following are some essential points to consider to increase your claim acceptance rates:
Provide Detailed Documentation
Documentation is the most essential part of 64494 claims. Without proper documentation, your claims are sure to be denied. To support the billing of 64494, you must provide the following details:
- Clear indication of what is being requested.
- Results of any diagnostic tests.
- Disability scale rating or a pain score (e.g., VAS 7/10) that clearly describes functional disability for each new episode of pain.
- Documented evidence of failed conservative management.
- Medical history records.
- Pain history, including location, severity, and duration.
- Patient response to prior facet joint interventions, if applicable.
- Physician orders and progress notes.
- Procedure records.
- Signature attestation form, if applicable.
Get Prior Authorization
Since July 1, 2023, the Centers for Medicare & Medicaid Services (CMS) has implemented a new policy for facet joint injections, including CPT code 64494. As per this new policy, prior authorization is required for facet joint interventions in hospital outpatient settings.
However, this requirement does not apply to physician offices, ambulatory surgery centers, or critical access hospitals.
Verify the Medicare Reimbursement Rate
According to the latest Medicare Physician Fee Schedule, the national average reimbursement for CPT code 64494 is $87.98 in non-facility settings and $49.17 in facility settings.
However, this rate varies significantly for each Medicare Administrative Contractor (MAC) locality. You can check the exact amount for your MAC via the PFS Lookup Tool.
Wrapping Up
Finally, our guide ends here. In this detailed guide, we tried our best to simplify CPT code 64494 for you. We covered a lot of information in this blog, so we hope that you took notes of the essential points. If you didn’t, let’s do a quick recap:
- Code 64494 is an add-on code for facet joint injections. It is used for diagnostic and therapeutic purposes in pain management.
- Modifiers 50 and KX should be used when appropriate. Do not use modifier 59.
- You must submit detailed documentation with your claim.
- If the services were performed in a hospital outpatient setting, make sure you provide the prior authorization number.
However, if you are facing continuous denials or do not have a specialized pain management billing team, you can always seek professional help. Many billing companies, such as MediBillMD, offer affordable pain management billing services to help reduce your administrative workload.
