MLN Matters Number: MM6518 Revised
Related Change Request (CR) #: 6518
Related CR Release Date: July 31, 2009
Effective Date: August 31, 2009
Related CR Transmittal #: R526PTN
Implementation Date: August 31, 2009

Note: This article was revised on August 10, 2009, to reflect a revision made to CR 6518. The transmittal number (see above) and the Web address for accessing CR 6518 have been changed. All other information remains the same. 

Provider Types Affected
Physicians and providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FI) and Medicare Administrative Contractors (MAC)) for facet joint injections performed on Medicare beneficiaries.

Provider Action Needed
This article clarifies the appropriate use of CPT modifier 50 and add-on codes for facet joint injection services. Physicians who perform facet joint injections on both the right and left sides of one level of the spine must use CPT modifier 50 with the appropriate CPT codes when submitting claims. Physicians who perform facet joint injections on multiple levels on the same side of the spine must use the CPT add-on codes to represent these additional levels injected, instead of using CPT modifier 50. Physicians should ensure that billing staffs are aware of this clarification.

Background
Facet joints are joints in the spine that aid stability and allow the spine to bend and twist. Facet joint injections are a type of interventional pain management technique used to diagnose or treat back pain. The CPT codes used for facet joint injections are:

The primary CPT codes, 64470 and 64475, are used for a single injection in the cervical/thoracic or lumbar/sacral area of the spine, respectively. Each primary code has an associated add-on code for use when injections are provided at multiple spinal levels. The add-on CPT codes are 64472 (cervical/thoracic) and 64476 (lumbar/sacral).

Bilateral injections are performed on the right and left sides of one joint level. The Centers for Medicare & Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing CPT modifier 50 and the appropriate CPT code. If a physician performs multiple bilateral injections, CPT modifier 50 should accompany each facet joint injection CPT code.

The Office of the Inspector General (OIG) recently conducted a medical record review of facet joint injection services performed in 2006 and released a final report, entitled, ‘Medicare Payments for Facet Joint Injection Services,’ OEI-05-07-00200. The OIG found that physicians incorrectly billed additional add-on CPT codes to represent bilateral facet joint injections instead of using CPT modifier 50. This report is viewable at www.oig.hhs.gov/oei/reports/oei-05-07-00200.pdf (PDF, 929 KB).

To summarize, when facet joint injections are performed on both the right and left sides of a level of the spine, physicians must use CPT modifier 50 and the appropriate primary CPT code. When facet joint injections are performed at more than one level, physicians must use add-on CPT codes 64472 or 64476 to represent additional levels of the spine injected.

Additional Information
If you have questions, please contact our Provider Contact Center are our toll-free number at (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina).

The official instructions may be viewed at www.cms.hhs.gov/Transmittals/downloads/R526OTN.pdf (PDF, 105 KB).

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.

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