Facet joint interventions may be used in pain management for chronic cervical/thoracic and back pain arising from the paravertebral facet joints. The facet block procedure is an injection of a local anesthetic, with or without a steroid medication, either into the facet joint (intra-articular) or outside the joint space around the nerve supply to the joint (the medial branch nerve) known as medial branch block (MBB). Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or back pain confirmed as originating in the facet joint’s medial branch nerve.
To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.
Covered Procedure Codes
64490 |
64491** |
64493 |
64494** |
64633 |
64634** |
64635 |
64636** |
64999* |
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|
|
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*Note: Procedure code 64999 should be reported when facet cyst aspiration/rupture is performed.
**Note: Procedure codes 64491, 64494, 64634, and 64636 need to be listed separately in addition to a code for the primary procedure.
Not Medically Necessary Procedure Codes
64492 |
64495 |
64999* |
0213T |
0214T |
0215T |
0216T |
0217T |
0218T |
0219T |
0220T |
0221T |
0222T |
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*Note: Procedure code 64999 is non-covered when used to report non-thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius), or any form of pulsed radiofrequency.
Covered Diagnosis Codes for Procedure Codes 64490, 64491, 64493, 64494, 64633, 64634, 64635, 64636, and 64999
M47.812 |
M47.813 |
M47.814 |
M47.815 |
M47.816 |
M47.817 |
M47.892 |
M47.893 |
M47.894 |
M47.895 |
M47.896 |
M47.897 |
M48.12 |
M48.13 |
M48.14 |
M48.15 |
M48.16 |
M48.17 |
M71.30* |
M71.38* |
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Refer to Medicare Advantage medical policy A-4 Monitored Anesthesia Care for additional information.
Refer to Medicare Advantage medical policy N-94 Computed Tomography – NCD 220.1 for additional information.
Refer to Medicare Advantage medical policy N-206 Acupuncture – NCD 30.3, 30.3.1, 30.3.2, 30.3.3 for additional information.
Refer to Medicare Advantage medical policy Z-56 Trigger Point Injections for additional information.
Refer to Medicare Advantage medical policy Z-97 Epidural Injections for Pain Management for additional information.
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