CPT NEW DESCRIPTION
64635 New code Destruction by neurolytic agent paravertebral facet joint nerve(s) (fluoroscopy or CT; Lumbar or sacral, single facet joint
(For bilateral procedure, report 64635 with modifier 50)
64636 New code Lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
Paravertebral Facet Joint Denervation
1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.
2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).
3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.
Revision History Number/Explanation
01/01/2012 CPT 2012 code update deleted codes 64622, 64623, 64626 and 64627, added new codes 64633, 64634, 64635, and 64636 removed codes 77003, 77012 and references to them. 08/01/2011 correction to Paravertebral Facet Joint Denervation number 3. Fluoroscopic guidance and localization for needle placement, is not included in codes 64622-64627 effective 03/18/2010.
Coverage Indications, Limitations, and/or Medical Necessity
A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. For the purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right.
Facet joint pain is generally suspected in patients with cervical, thoracic and or lumbar pain that may or may not have a radicular component, when focal tenderness is present over the facet joint, and increased symptoms due to rotation or extension of the spine.
Destruction of a paravertebral facet joint nerve(s) requires the use of fluoroscopic guidance to confirm the proper positioning of the needle or electrode at the level of the involved paravertebral facet joint(s). Destruction of the paravertebral facet joint nerve (s) (median branch) can then be achieved by means of thermal, electrical or radiofrequency (rhizotomy) applications. Facet joint nerve destruction is considered a definitive form of treatment for facet joint pain. Therefore, it would not be expected to see multiple repeat facet joint destruction procedures performed once all of the involved facet joints at that spinal level on either side have been denervated. However, the nerves do have the ability to regenerate. If pain recurs in the same distribution and nature, the procedure may be provided at a maximum of two (2) sessions per year (per 12 months).
Indications
The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows:
• The paravertebral facet joint(s) have been identified as the source of the patient’s pain by undergoing a diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and
• The patient failed conservative treatment. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic and
• The paravertebral facet joint(s) destruction is performed by appropriately trained providers.
The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services are "ordered and/or furnished by qualified personnel."
A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.
Limitations
The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary when:
• Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint (median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or
• The medical records do not support that the patient experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection; or
• The medical records do not demonstrate that destruction was performed at the median branch of the spinal nerve innervating the facet joint.
| Group 1 Codes | |
|---|---|
| 64633 | Destroy cerv/thor facet jnt |
| 64634 | Destroy c/th facet jnt addl |
| 64635 | Destroy lumb/sac facet jnt |
| 64636 | Destroy l/s facet jnt addl |
A patient undergoes a radiofrequency nerve destruction of two medial branch nerves L3 and L4 innervating the symptomatic lumbar facet joint. Reimbursement consideration is based upon the following code selection:
* 64635 — $516.47 (approximate 2012 ASC reimbursement) Coding tips:
* Image guidance and localization are required for the performance of paravertebral facet joint nerve destruction by neurolytic agent described by 64633-64636.
* Do not report 64633-64636 in conjunction with 77003 or 77012). Both CPT 77003 and/or 77012 are considered inclusive to the injection procedure in 2012. Note: If CT or fluoroscopic imaging is not used/documented, report unlisted CPT code 64999.
* If both facet joints at the same vertebral level are treated, then CPT 64633 or 64635 should be reported with modifier -50 appended pending carrier reporting requirements for bilateral procedures (-50 versus RT/LT versus units).
ICD-10 Codes that Support Medical Necessity
| M47.011 | Anterior spinal artery compression syndromes, occipito-atlanto-axial region |
| M47.012 | Anterior spinal artery compression syndromes, cervical region |
| M47.013 | Anterior spinal artery compression syndromes, cervicothoracic region |
| M47.014 | Anterior spinal artery compression syndromes, thoracic region |
| M47.015 | Anterior spinal artery compression syndromes, thoracolumbar region |
| M47.016 | Anterior spinal artery compression syndromes, lumbar region |
| M47.019 | Anterior spinal artery compression syndromes, site unspecified |
| M47.021 | Vertebral artery compression syndromes, occipito-atlanto-axial region |
| M47.022 | Vertebral artery compression syndromes, cervical region |
| M47.029 | Vertebral artery compression syndromes, site unspecified |
| M47.11 | Other spondylosis with myelopathy, occipito-atlanto-axial region |
| M47.12 | Other spondylosis with myelopathy, cervical region |
| M47.13 | Other spondylosis with myelopathy, cervicothoracic region |
| M47.14 | Other spondylosis with myelopathy, thoracic region |
| M47.16 | Other spondylosis with myelopathy, lumbar region |
| M47.21 | Other spondylosis with radiculopathy, occipito-atlanto-axial region |
| M47.22 | Other spondylosis with radiculopathy, cervical region |
| M47.23 | Other spondylosis with radiculopathy, cervicothoracic region |
| M47.24 | Other spondylosis with radiculopathy, thoracic region |
| M47.25 | Other spondylosis with radiculopathy, thoracolumbar region |
| M47.26 | Other spondylosis with radiculopathy, lumbar region |
| M47.27 | Other spondylosis with radiculopathy, lumbosacral region |
| M47.28 | Other spondylosis with radiculopathy, sacral and sacrococcygeal region |
| M47.811 | Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region |
| M47.812 | Spondylosis without myelopathy or radiculopathy, cervical region |
| M47.813 | Spondylosis without myelopathy or radiculopathy, cervicothoracic region |
| M47.814 | Spondylosis without myelopathy or radiculopathy, thoracic region |
| M47.815 | Spondylosis without myelopathy or radiculopathy, thoracolumbar region |
| M47.816 | Spondylosis without myelopathy or radiculopathy, lumbar region |
| M47.817 | Spondylosis without myelopathy or radiculopathy, lumbosacral region |
| M47.818 | Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region |
| M47.891 | Other spondylosis, occipito-atlanto-axial region |
| M47.892 | Other spondylosis, cervical region |
| M47.893 | Other spondylosis, cervicothoracic region |
| M47.894 | Other spondylosis, thoracic region |
| M47.895 | Other spondylosis, thoracolumbar region |
| M47.896 | Other spondylosis, lumbar region |
| M47.897 | Other spondylosis, lumbosacral region |
| M47.898 | Other spondylosis, sacral and sacrococcygeal region |
| M54.2 | Cervicalgia |
| M54.30 | Sciatica, unspecified side |
| M54.31 | Sciatica, right side |
| M54.32 | Sciatica, left side |
| M54.5 | Low back pain |
| M54.6 | Pain in thoracic spine |
| M96.1 | Postlaminectomy syndrome, not elsewhere classified |