Nerve pain in the spine is among the most frequently faced ailments by healthcare providers. Oftentimes, simple medication is not enough to manage the severe pain that patients feel. So, interventional pain management is required. However, pain management billing can be a headache.
A commonly used billing code in pain management is CPT code 64493. Yet, it is also one of the most misunderstood. If you have ever faced a denial for this code, don’t worry, you are not alone. Many billers face the same problem.
That’s why we have created this detailed guide on the 64493 CPT code. By the end of this guide, you will have all the necessary information to file this code correctly. So, let’s start.
CPT Code 64493 – Description
CPT code 64493 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; single level.”
Let’s try to break this down in simpler terms.
Code 64493 is a pain management billing code. It can be used for both diagnostic and therapeutic purposes. During the procedure, the physician places the injection needle into the targeted lumbar facet joint or surrounding nerve structures under fluoroscopic or CT guidance. Once the needle is placed into the correct position, a diagnostic or therapeutic drug is administered.
The diagnostic component of CPT 64493 serves to identify whether the targeted facet joint is the source of the patient’s pain. In this scenario, the physician inserts a local anesthetic, like lidocaine. The patient is then monitored for changes in pain level. A positive diagnostic response typically requires at least 50% pain relief.
On the other hand, if CPT 64493 is used for therapeutic purposes, other medicines like corticosteroids, along with anesthetic drugs, are administered. Also, an essential point that many billers miss is that for 64493 to be valid, imaging guidance is mandatory. Without imaging, you cannot bill a claim with 64493.
Scenarios Where CPT Code 64493 is Applicable
Let’s make things clearer with some real-world scenarios in which CPT code 64493 is applicable.
Lumbar Spondylosis
Suppose a 65-year-old man visits a medical practice. He tells the attending physician that he has chronic lower back pain that has progressively worsened over six months. He also shares that the pain is only in the lumbar region and there is no pain or numbness in the legs. To properly diagnose the condition, the physician orders imaging tests. The tests show degenerative changes consistent with lumbar spondylosis.
The patient tells the physician that he has tried conservative treatments and basic pain medication. However, nothing seems to work. The physician decides to perform a paravertebral facet joint injection with imaging guidance at the first lumbar level to alleviate the patient’s symptoms. In this scenario, the billing department can use CPT code 64493 to bill the facet joint injection.
Ankylosing Hyperostosis
Let’s consider another scenario.
Suppose a 60-year-old patient arrives at the clinic with severe low back stiffness and aching pain that limits daily activities like bending or walking. He has a history of spinal bone overgrowth without inflammatory arthritis signs. These symptoms suggest excessive bone formation along the lumbar vertebrae, a condition known as ankylosing hyperostosis (Forestier) in the lumbar region.
However, to manage chronic pain and assess response, the physician administers a therapeutic agent injection with fluoroscopy. Similar to our first scenario, the billing department can use CPT code 64493 to bill for the administration.
Applicable Modifiers for CPT Code 64493
The following are some of the modifiers that can be used with CPT code 64493:
| 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
CPT Code 64493 – Billing & Reimbursement Guidelines
The following are some essential points to consider to increase your claim acceptance rates:
Provide Comprehensive Documentation
Documentation is key to getting your claims reimbursed. Without proper documentation, insurance payers will reject your claim. To justify the medical necessity of the service, you must append the following documentation with your claims:
- Clear indication of what is being requested.
- Diagnostic test results.
- Disability scale rating or an H/P that clearly describes functional disability for each new episode of pain.
- 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.
Check Pre-Authorization Requirements
CMS created a new policy regarding prior authorization of facet joint injections that became effective on July 1, 2023. As per this policy, hospital outpatient departments must now obtain prior authorization for the CPT code 64493. 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 64493 is $172.08 in non-facility settings and $88.31 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
In this blog, we tried our best to simplify CPT code 64493 for you. It is an important billing code and has a high reimbursement rate. So, healthcare providers cannot afford to get this wrong. By following the guidelines that we mentioned above, you can confidently file your 64493 claims.
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.
