Facet Joint Interventions for Pain Management

General Documentation Requirements for Facet Joint Interventions

  • Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale
  • Presence of pain for minimum of 3 months with documented failure to respond to conservative management
  • Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)
  • Non-facet pathology must be ruled out based on clinical evaluation or radiology studies
  • The scales used to assess the measurement of pain and/or disability must be obtained at baseline and documented in the medical record for each assessment (refer to your MAC's LCD/LCA).
  • There is more individual criteria DEPENDENT UPON which type of facet procedure is being performed; please refer to criteria in LCD.

Coverage Criteria

LCD - Facet Joint Interventions for Pain Management (L38801)

Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58403)

Codes

Codes Description
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)
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)
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)

Note: The following CPT codes were removed on August 16, 2024, and no longer require prior authorization:

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))

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))

Three (3) or four (4) level procedures are not medically necessary and therefore are non-covered.

The Prior Authorization for Certain Hospital Outpatient Department Part B Associated Codes List is in Appendix B of the CMS OPD Operational Guide.

Resources

Last Updated Aug 13 , 2024