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CMS Clarifies Facet Joint Injections Billing

August 11, 2009:

A recent Medicare transmittal has specified the proper billing of bilateral facet joint injections. The transmittal, published in July, addresses more than $100 million in improper payments to physicians and facilities identified by the Office of Inspector General (OIG).

An OIG investigation revealed that 63 percent of all facet joint injections allowed did not meet Medicare program requirements and resulted in approximately $96 million in improper payments to physician providers and another $33 million in improper payments to facilities. The transmittal specifically addresses billing of bilateral services, which accounted for 60 percent of the errors. See Ingenix Insights article “Facet Joint Injections Often Don’t Meet Payer Requirements,” posted on February 24, 2009.

According to the transmittal, modifier 50 should be appended when the documentation states that injections were made on the same level but on different sides. A physician should never use add-on code 64472 or 64476 when the documentation indicates that the injections were performed bilaterally. For example, if the documentation states that a facet joint was injected at the L2 level bilaterally, code 64475 should be reported with modifier 50, bilateral procedure, appended. 

NOTE: Report the name and dosage of the anesthetic and/or steroid agent administered with the appropriate HCPCS level II code separately.

Codes 64472 and 64476 are add-on codes identifying each additional level for the respective anatomical locations and as such are never reported as stand-alone codes and are also modifier 51 exempt. According to the Medicare Physician Fee Schedule Database for 2009, the standard multiple procedure (modifier 51) and standard bilateral surgery adjustments apply to these codes. Assistant-at-surgery (modifiers 80, 81, and 82), cosurgery (modifier 62), and surgical-team (modifier 66) concepts do not apply and therefore would not be paid for separately.


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