Imagine you just finished a grueling week in the clinic. You successfully diagnosed your last patient’s cervical pain, performed a precise facet joint injection, and finally provided him the relief he has been seeking for months. You documented the procedure, submitted the claim, and started your new week. However, days later, your claim is denied. The reason? Inaccurate use of CPT code 64490 and modifiers.
This is a common scenario at pain management practices. That’s why our experts have created this detailed guide on 64490, so you don’t have to face denials anymore. Let’s start.
CPT Code 64490 – Description
CPT code 64490 is defined as:
“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.”
64490 is a pain management billing code. This code is used for both therapeutic and diagnostic purposes. It represents the primary paravertebral injection for a single level in the cervical (neck) or thoracic (upper back) spine.
To better understand the code, let’s briefly discuss how the procedure is performed.
During the procedure, the physician first places the injection needle in the correct position at the cervical/thoracic facet joint or surrounding nerve structures. This is usually done with the help of fluoroscopy or CT imaging. Once the needle is placed into the correct position, a diagnostic or therapeutic drug is administered.
There are two critical components to remember about CPT code 64490:
- Image Guidance is Bundled: The code descriptor explicitly states “with image guidance (fluoroscopy or CT).” This means that the payment for imaging is already bundled in the code’s reimbursement amount. Therefore, you cannot bill fluoroscopy separately using codes like 77002 or 77003.
- Primary Code Status: 64490 is the parent code. It is used for the first-level injection. If you treat additional levels in the cervical or thoracic spine during the same session, you must use the appropriate add-on codes (64491 for the second level, 64492 for the third) rather than repeating the primary code.
Scenarios Where CPT Code 64490 is Applicable
Now that we have explained what CPT code 64490 is, let’s discuss a couple of real-world scenarios in which it can be used:
Spondylosis without Myelopathy
Suppose a patient comes to a clinic with persistent neck pain and stiffness that worsens with movement. The pain is localized to the cervical region without radiating to the arms or neurological deficits. The patient shares that he has previously tried many treatment options suggested by other physicians. However, nothing has relieved the pain. Upon further evaluations and checking the patient’s medical treatment history, the physician discovers degenerative changes in the cervical spine, a condition known as cervical spondylosis.
However, to confirm the diagnosis and pinpoint the source of the pain, he performs a diagnostic facet joint injection under fluoroscopic guidance at the C5-C6 level. The billing department can bill the procedure using CPT code 64490 and diagnosis code ICD-10 M47.812.
Facet Arthropathy
Suppose a 68-year-old patient arrives at the clinic complaining of chronic neck stiffness and aching pain that limits his range of motion. Imaging reveals degeneration along the cervical spine, indicating facet arthropathy. To provide therapeutic relief and reduce inflammation in the affected facet joint, the physician administers a corticosteroid injection at the C4-C5 level using fluoroscopic guidance.
After that, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 64490 is used.
Applicable Modifiers for CPT Code 64490
Modifiers tell the complete story of a procedure. Without appropriate modifiers, your claims will be denied. The following are the most used modifiers with CPT code 64490:
| 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: Modifiers RT and LT are only to be used by ambulatory surgical centers (ASCs). Do not use them if the procedure is performed in other settings.
CPT Code 64490 – Billing & Reimbursement Guidelines
To get fair reimbursement for your services, always consider the following points while filing claims for CPT code 64490:
Attach Detailed Documentation
Documentation is vital if you want to justify the medical necessity of your services and collect reimbursements for your claims. Without detailed documentation, your claims are sure to be rejected. For 64490, you must provide the following details:
- Signed attestation form, if applicable
- Procedure records.
- Medical history records.
- Evidence of failed conservative management.
- Pain history, including location, severity, and duration.
- Diagnostic test results.
- Disability scale rating or an H/P that clearly describes functional disability for each new episode of pain.
- Clear indication of what is being requested.
- Physician orders and progress notes.
- Patient response to prior facet joint interventions, if applicable.
Make Sure to Get Prior Authorization
Since July 1, 2023, CMS has implemented a Prior Authorization program for hospital outpatient department (OPD) services for facet joint interventions. Failing to obtain this can result in automatic claim denials.
Please note that 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 64490 is $186.32 in non-facility settings and $102.21 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
With that, we have reached the end of this guide. We discussed in detail what CPT code 64490 is and how you can use it effectively in your claims. Let’s recap the essential points, in case you missed anything:
- 64490 is the primary code for cervical/thoracic facet joint injections.
- Append necessary modifiers where appropriate.
- Provide detailed documents with your claims to justify the medical necessity.
Pain management billing can be challenging even for experienced billing teams. It is better to let professionals handle your medical billing and coding operations. Many companies, like MediBillMD, offer premium pain management billing services at affordable rates.
