Individuals worldwide commonly suffer from upper back and neck pain, mainly because of postural stress and poor lifestyle. This can lead to degenerative changes in the spine, such as structural spinal disorders and musculoskeletal strain.
According to a study by the National Institutes of Health, globally, 203 million people suffered from neck pain in 2020. Therefore, medical practitioners will likely encounter such patients and should learn how billing guidelines for CPT code 64490 work.
It is a procedural code used to report interventions for musculoskeletal conditions of the paravertebral facet (zygapophyseal) joints, which are a common cause of axial pain. When patients don’t get relief from basic treatment, physicians or pain management experts use image-guided facet joint injections to treat or diagnose the pain.
CPT Code 64490 – Description
CPT code 64490 is defined as:
A diagnostic or therapeutic, single-level injection administered to the paravertebral facet (zygapophyseal) joint (or its medial branch nerves) via image guidance for the cervical or thoracic regions.
CPT 64490 to 64495 indicate injection administration within the paravertebral region. However, 64490 is used for an injection into the cervical or thoracic paravertebral joint at a single level.
It is reported once per treated facet joint level. However, the laterality guidelines differ. You can read more about it in the section ‘Modifiers to Append with CPT Code 64490’.
Cases Where CPT Code 64490 Applies
Injectable interventions are medically necessary for the diagnosis or treatment of chronic pain. Therefore, let us discuss three clinical scenarios where CPT code 64490 applies to comprehend accurate usage.
Chronic Cervical Spondylosis with Axial Neck Pain
Consider a 63-year-old male with a multi-year history of severe axial neck pain, limiting daily tasks. He arrives at the physician’s clinic but reports no arm pain or tingling. Similarly, the patient does not exhibit any neurological symptoms either.
A three-month pain history is documented as the patient does not respond to conservative measures, including NSAIDs and therapy. The medical practitioner also rules out radiculopathy after clinical assessment.
Next, the physician performs a fluoroscopy-guided diagnostic medial branch block at a single C5-C6 facet joint level for the pain source. Lastly, the billing team uses CPT code 64490 and reports spondylosis without myelopathy or radiculopathy, cervical region as the diagnosis (ICD-10-CM M47.812).
Cervicothoracic Facet Syndrome
Consider the case of a 55-year-old male with moderate axial pain, without radiculopathy. The physician begins with the patient’s history of three months of documented pain and management failure.
In the patient’s history, the physician also finds several non-invasive treatments, such as physical therapy and oral analgesics, indicating no positive outcome. Therefore, the physician uses image-guided facet joint intervention for diagnosing the pain.
He administers a CT-guided injection at a single cervicothoracic level and uses CPT code 64490 for billing and reimbursement. Here, to justify medical necessity, the physician will pair the CPT code with diagnosis code M47.813 for spondylosis without myelopathy or radiculopathy, cervicothoracic region.
Thoracic Facet-Mediated Pain from Degenerative Changes
Say a 68-year-old female presents to the physician’s clinic for chronic upper-to-mid back pain. The thoracic facet joint-mediated pain persists despite 8 weeks of non-invasive treatment.
The physician assesses the patient further to rule out neurogenic claudication and untreated radiculopathy. Furthermore, the patient shows no sign of a:
- Tumor
- Significant deformity
- Infection
- Fracture
Thus, the medical practitioner opts for fluoroscopy-guided facet joint intra-articular injection at the single level. The procedure is billed using CPT code 64490 along with ICD-10-CM M47.814 (spondylosis without myelopathy or radiculopathy, thoracic region).
Modifiers to Append with CPT Code 64490
Errors in selecting modifiers negatively impact reimbursements, revenue cycles, and practice reputation. Therefore, medical billing teams should rightfully identify modifiers applicable to CPT code 64490. The following modifiers may apply to the procedural code, depending on the patient’s condition and scenario.
| Modifier | Description | When to Use with CPT 64490 |
|---|---|---|
| 50 | Bilateral procedure | Appended when physicians inject both sides of the facet joints within the same vertebral level during the same session. |
| KX | Medical policy requirements are met | Reported when payer-specific medical necessity requirements have been met. |
| LT | Left side | Indicates the unilateral injection was administered on the left side of the body. |
| RT | Right side | Reports that the unilateral injection was delivered on the right side of the body. |
Important Notes for Using Modifiers
- The CPT code is reported once per level regardless of the side, and modifier LT/RT or 50 may be used for reporting laterality or bilaterality.
- Payers may require either modifier 50 or LT and RT on separate claim lines, depending on their billing policy.
- For modifier KX, the documentation must clearly mention that all requirements are met, per CMS billing guidance (A57826).
Reimbursement Guidelines for CPT Code 64490
For the successful reimbursement of CPT 64490, you must fulfill the following requirements.
Medical Necessity Criteria
According to the CMS guideline, the procedure represented by CPT code 64490 is medically necessary if it fulfills the following conditions:
- Zero evidence of active radiculopathy or neurogenic claudication.
- Persistent pain for 3 months or more despite non-invasive management measures.
- Substantial neck or back pain hindering daily functioning.
Pain assessment must be documented at baseline and after each diagnostic procedure using the same pain scale. A disability scale must also be obtained at baseline for functional assessment.
Session and Frequency Limitations
The following session frequency limitations apply:
- Injections may be administered to up to two bilateral or unilateral levels in a session.
- CPT code 64490 cannot be reported for more than 4 sessions per spinal region within a 12-month rolling period.
- Facet joint interventions are typically limited to one spinal region per session unless medically required and justified.
- Typically, patients should not present with thoracic, cervical, and lumbar areas concurrently. However, there are exceptions:
Special Exception Scenario: Billing teams may report contiguous facet interventions at T12-L1 and L1-L2 in a single session, which are considered a single lumbar region.
Documentation Requirements
According to the latest requirements, the medical documents supplemented with the claim should include:
- A clinical assessment from the physician regarding the patient’s reason for the visit.
- Patient’s detailed medical history.
- Appropriate tests, procedures, and their results.
- Substantial proof of previously failed conservative treatment.
- Operative report and dated office notes (signed by the physician).
Important Note: All documents submitted must include the patient’s complete name, service dates, and the physician’s signature.
Prior Authorization Requirements
If the injection in the paravertebral facet joint (CPT 64490) was administered at a Hospital Outpatient Department (HOPD), prior authorization is required. Therefore, prior authorization must be obtained before the procedure to avoid denials.
Bundled Imaging Guidance
CT imaging guidance and fluoroscopy are bundled into CPT code 64490. Therefore, billing teams must never report them separately, or the claim will be denied.
Anesthesia Restrictions
Medicare does not consider moderate, deep sedation, general anesthesia, or monitored anesthesia care as medically necessary for facet injections. So, administering anesthesia or wrongfully reporting it can trigger a detailed medical review.
Reimbursement Rates
The national average Medicare reimbursement rate for CPT code 64490 is $205.08 in non-facility settings and $94.19 in facility settings. However, factors such as geographic locality can also impact the final reimbursable amount.
Thus, billing teams should review the Physician Fee Schedule Lookup Tool to see the actual reimbursement rate for their Medicare Administrative Contractor (MAC) locality.
Final Thoughts on CPT Code 64490
CPT code 64490 indicates a single-level, image-guided injection administered for diagnostic or therapeutic reasons into the cervical or thoracic paravertebral facet joint. CT and fluoroscopy are a part of this code and should not be billed separately.
This CPT code’s claim adjudication requires meeting the medical necessity criteria. It can be done via attaching relevant documents, using an accurate modifier, and obtaining prior authorization. If your in-house billing team experiences frequent claim denials, outsourcing coding might be your best bet. Third-party pain management billing services include CPT coding at the hands of certified professional medical coders.
