Physicians use many different techniques to alleviate pain in the small joints located in pairs on the back of the spine, so it's easy to get confused when coding facet injections and facet nerve destructions. Here are three mistakes I see most often during compliance audits:

• under- or over-reporting additional levels;
• not billing fluoroscopy use appropriately; and
• reporting multiple injections for the same level.

This article, and the five-question quiz on the next page, will help clear the confusion.

Anatomy lesson
First, let's discuss CPT codes 64470 to 64476 (injection, anesthetic agent or steroid, paravertebral facet joint or facet joint nerve, cervical, thoracic, lumbar and sacral), which you report per spinal level. The vertebra in the spine are joined to the one above and below by articular facet joints. There are four facet joints associated with each vertebra in the spine below the level of C2 and above the level of S1. This means at the vertebral level of C4, there is a C3-4 facet joint at the upper end and also a C4-5 facet joint at the lower end.

Generally, each facet joint has dual innervations: one from the dorsal rami at the same level and one from the level above (the C4-5 cervical facet joint is innervated by the medial branches of the dorsal rami from C3 and C4. Because it's difficult to isolate the exact joint level affected, physicians frequently perform multiple injection levels when treating neck and back pain. Some third-party payers have specific guidelines for multiple-level injections so it's best to check with them for their individual policies. Keep these rules of thumb in mind:

• Report these injections when performed on the left or the right with the appropriate laterality modifier.
• When these injections are performed at both the left and right paravertebral facet joints at the same level, append the bilateral modifier -50 to the CPT code.
• CPT code 64472 and 64476 are add-on codes. As such, they're exempt from the multiple procedure concept, so you shouldn't append the -51 modifier to them. The -51 modifier isn't an approved ASC modifier per CPT. Unless a carrier has requested its use in writing, surgical centers shouldn't use the -51. Add-on codes are exempt from the -51 in any setting. You can find these exemptions in appendix E of the CPT book.

Common coding quandaries
Here are a few sticking points your coders might encounter.

• Multiple needle technique. How do you report a case in which a physician inserts the needle once and injects a drug (a steroid, for example) and then changes the syringe and injects the next drug (an anesthetic, for example)? Report only one facet injection code at a specified level and side injected, regardless of the number of needles inserted or number of drugs injected at that specific level, according to CPT Assistant, September 2004.

Regardless of whether you inject the facet joint by injection into the joint with one needle puncture or by anesthetizing the two medial branch nerves that supply each joint (two needle punctures), code these as one level.

• Will payers reimburse you for fluoroscopy? Your physician will use fluoroscopic guidance to ensure that he directs the needle into the facet joints or facet joint nerves to prevent complications. The CPT book states, just below code 64470, that "if fluoroscopic guidance and localization for needle placement and injection is performed in conjunction with (64470 to 64484), consult CPT code 76005." CPT guidelines let you separately report fluoroscopy for these procedures. If your facility owns or pays for the C-arm, report 76005-TC. The -TC modifier indicates that the facility supplied the equipment and is seeking reimbursement for that purpose. The physician will also report the 76005, but with a -26 modifier that indicates the professional component.
• Nerve destruction. Use CPT codes 64622 to 64627 to report destruction by neurolytic agent, paravertebral facet joint nerve lumbar, sacral, cervical and thoracic. The neurolytic agent can be chemical, thermal, electrical or radiofrequency. These codes are unilateral, so the appropriate laterality modifier will apply - depending on which side the physician performs the injection. Again, if the doctor performs injections on the left and right of the same level, report these codes with the bilateral modifier of -50. Many times the physician will inject other therapeutic agents at the time of the procedure (steroids, for example) and this is inclusive of the destruction procedure. You can find this guideline in the CPT book underneath the section heading of the 64600 to 64640 range of codes.

Facet destruction codes 64622 to 64627 refer to individual nerve level destruction. This is different from facet injections, which are coded per level. For example, you'd code destruction of the right L4 and L5 medial branch nerves as 64622 and 64623, whereas you'd code an injection of the right L4 and L5 medial facet joint nerve as 64475.

Pain relief
The purpose of paravertebral facet joint or facet joint nerve injections is to interrupt pain signals of facet joint origin from reaching the brain. The purpose of steroid injection is to reduce inflammation and swelling of tissue in or around the joint space which may in turn reduce pain and other symptoms caused by inflammation and irritation of the joint and surrounding structures. If there's a favorable response to these injections, then you may consider more permanent techniques for the treatment of facet pain, such as destruction of the nerve, which blocks the passage of painful messages from the affected facet joint to the rest of the central nervous system.