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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-30

Original Effective Date: 02/15/04

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Facet Joint Injections

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Facet joints (also called zygapophysial joints or z-joints), are posterior to the vertebral bodies in the spinal column and connect the vertebral bodies to each other, They are located at the junction of the inferior articular process of a more cephalad vertebra, and the superior articular process of a more caudal vertebra. These joints provide stability and enable movement, allowing the spine to bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.

Facet joints are clinically important spinal pain generators in those with chronic spinal pain. Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult, as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck and shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome’, a term referring to back pain caused by pathology at the facet joints. Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting candidates for controlled local anesthetic blocks of either the medial branches or the facet joint itself. This is an established tool in diagnosing facet joint syndrome.

Facet joint interventions are used in the treatment of pain in certain individuals with a confirmed diagnosis of facet joint pain. Interventions include intra-articular injections and medial branch nerve blocks in the affected region. Facet joint injections or medial branch nerve blocks require guidance imaging.

POSITION STATEMENT:

Facet joint injection meets the definition of medical necessity when ALL of the following are met:

*Thoracic facet joint injection is considered experimental or investigational. Data in published medical literature are inadequate to permit scientific conclusions on long-term and net health outcomes.

Facet joint injection performed with ultrasound guidance is considered experimental or investigational. The evidence is insufficient to permit conclusions on efficacy and net health outcomes.

Frequency of facet joint injections:

*Conservative non-operative therapy(spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections ( including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic care.

** A home exercise program (HEP) must consist of the following two elements:

1. Information on an exercise prescription/plan is provided to the member

2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises). NOTE: member inconvenience or noncompliance without explanation does not constitute inability to complete a HEP.

Contraindications for facet joint injections include:

BILLING/CODING INFORMATION:

CPT Coding

64490

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

64491

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

64492

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

64493

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

64494

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

64495

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

0213T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic, single level (investigational)

0214T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (investigational)

0215T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level (s) (list separately in addition to code for primary procedure) (investigational)

0216T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level (investigational)

0217T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) (investigational)

0218T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) (investigational)

ICD-10 Diagnoses Codes That Support Medical Necessity

M25.511, 512
M25.521, 522
M25.531,532
M25.551, 552
M25.571, 572

Pain in shoulder

M47.14 – M47.18

Other spondylosis with myelopathy

M47.812 – M47.817

Spondylosis without myelopathy or radiculopathy

M47.892 – M47.897

Other spondylosis

M47.9

Spondylosis, unspecified

M54.2

Cervicalgia

M54.5

Low back pain

M96.1

Postlaminectomy syndrome, not elsewhere classified

REIMBURSEMENT INFORMATION:

Refer to POSITION STATEMENT.

LOINC Codes

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician Initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology study report

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Paravertebral Facet Joint Blocks (L29252) and Noncovered Services (L29288) located at fcso.com.

DEFINITIONS:

Facet joint: each of four joints formed above and below and on either side of a vertebra by bony projections (articular processes). The smooth surface at the end of the bony projections is called a facet. Each vertebra has a bony projection on either side which angles downward on its lower side and a bony projection on either side that angles upward. The lower projections of one vertebra meet the upper projections of the vertebra below it, forming facet joints.

Paravertebral facet joint nerve: nerve innervating a facet joint. Each facet joint is innervated by two nerves that are branches of the posterior division of the spinal nerves immediately above and below the joint. Also known as medial branch nerve.

Somatic pain: a type of nociceptive pain. The nerves that detect somatic pain are located in the skin and deep tissues. These specialized nerves, called nociceptors, pick up sensations related to temperature, vibration and swelling in the skin, joints and muscles.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report facet joint injections:

Diagnostic medial branch block
Facet block
Spinal facet joint injections
Spinal facet joint nerve block
Zygapophyseal joint nerve block
Z-joint injection

REFERENCES:

  1. AHRQ National Guideline Clearinghouse Guideline Summary NGC-7951. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
  2. AHRQ National Guideline Clearinghouse Guideline Summary NGC-8967. Assessment and management of chronic pain. Institute for Clinical Systems Improvement (ICSI); 2011 Nov.
  3. AHRQ National Guideline Clearinghouse Guideline Summary NGC-9327. Low back disorders. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2011.
  4. AHRQ National Guideline Clearinghouse Guideline Summary NGC-8518. Neck and upper back (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011.
  5. Alemo, S. Sayadipour, A. Chronic Mechanical Lower Back Pain. J Neurolog Orthop Med Surg (2008) 28(1): 5-11.
  6. American Chronic Pain Association. ACPA Consumer Guide to Pain Medication & Treatment 2009. Epidurals, Nerve & Facet Blocks & Radiofrequency Ablation (Rhizotomy). Accessed on 04/03/09.
  7. Bani A, Spetzger U, Gilsbach JM. Indications for and benefits of lumbar facet joint block: analysis of 230 consecutive patients. Neurosurg Focus. 2002 Aug 15; 13(2): E11.
  8. Boswell MV, Shah RV, Everett CR, Sehgal N, Mckenzie-Brown AM, Abdi S, Bowman RC, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS, Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Phys 2005;8(1): 1-47.
  9. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan; 10 (1): 7-111.
  10. Canadian Agency for Drugs and Technologies in Health Rapid Response Report. Facet Joint Injection as Diagnostic and Therapeutic Tools for Pain of the Cervical and Lumbar Spine: A Review of Clinical and Cost-Effectiveness. 01/25/11.
  11. Civelek E, Cansever T, Kabatas S, Kircelli A, Yilmaz C, Musluman M, Ofluoglu D, Caner H. Comparison of Effectiveness of Facet Joint Injection and Radiofrequency Denervation in Chronic Low Back Pain. Turk Neurosurg. 2012;22(2):200-6.
  12. CPT 2000 Code and Guideline Changes: A Comprehensive Review (November 1999).
  13. ClinicalTrials.gov. NCT00613340 The Specificity of Cervical Facet Medial Branch Blocks. Johns Hopkins University and Army Regional Anesthesia and Pain Management Initiative. April 2009.
  14. Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic Assessment of Diagnostic Accuracy and Therapeutic Utility of Lumbar Facet Joint Interventions. Pain Physician. 2009 Mar-Apr; 12 (2): 437-460.
  15. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Facet Joint Injection Therapies for Chronic, Nonmalignant Back Pain. Updated 02/23/07.
  16. Edlow Bl, et al. Posterior Circulation Stroke after C1–C2 Intraarticular Facet Steroid Injection: Evidence for Diffuse Microvascular Injury. Anesthesiology 2010; 112:1532–5.
  17. Falco FJ, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, Hayek SM. Systematic Review of Diagnostic Utility and Therapeutic Effectiveness of Cervical Facet Joint Interventions. Pain Physician. 2009 Mar-Apr; 12(2): 323-344.
  18. First Coast Service Options, Inc. Local Coverage Determination Paravertebral Facet Joint Blocks. L29252, 10/04/11.
  19. First Coast Service Options, Inc. Local Coverage Determination Noncovered Services. L29288, 02/07/15.
  20. Florida Medicare Part B Local Coverage Determination # L6146 64470. Paravertebral Facet Joint Nerve Injection, (09/30/07). (Retired 02/01/09).
  21. Hayes, Inc. Hayes Medical Technology Directory. Facet Blocks for Chronic Back Pain. Lansdale, PA: Hayes, Inc.; October 2006.
  22. Hashimoto R, Raich A, Ecker, E, Henrikson N, Wallace L, Dettori J, Chou R. Spinal injections: Health technology assessment. Washington State Health Care Authority. November 10, 2010. Accessed July 6, 2011.
  23. Improving the Quality of Pain Management through Measurement and Action. Monograph developed by JCAHO as part of a collaborative project with NPC. Mar 2003.
  24. InterQual® 2012.2 Adult Procedures. Facet Joint Injections.
  25. InterQual® 2014. CP: Procedures : Facet Joint Injection.
  26. Jung H, Jeon S, Ahn S, Kim M, Choi Y. The Validation of Ultrasound-Guided Lumbar Facet Nerve Blocks as Confirmed by Fluoroscopy. Asian Spine Journal Vol. 6, No. 3N, 2012.
  27. Loizides A, Obernauer J, Peer S, Bale R, Galiano K, Gruber H. Ultrasound-guided injections in the middle and lower cervical spine. Med Ultrason. 2012 Sep;14(3):235-8.
  28. Manchikanti L, et al. An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part II: Guidance and Recommendations. Pain Physician 2013; 16:S49-S283.
  29. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician 2009; 12:699-802. (Accessed 08/21/13).
  30. Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin RM. A Preliminary Report of a Randomized Double- Blind, Active Controlled Trial of Fluoroscopic Thoracic Interlaminar Epidural Injections in Managing Chronic Thoracic Pain. Pain Physician. 2010 Nov-Dec.
  31. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Cervical epidural injections in chronic discogenic neck pain without disc herniation or radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010 Jul-Aug.
  32. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of Fluoroscopically Directed Facet Joint Nerve Blocks: A Prospective Evaluation of 7,500 Episodes with 43,000 Nerve Blocks. Pain Physician. 2012 Mar-Apr;15(2):E143-50.
  33. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic Cervical Interlaminar Epidural Injections in Managing Chronic Pain of Cervical Postsurgery Syndrome: Preliminary Results of a Randomized, Double-Blind, Active Control Trial. Pain Physician. 2012 Jan-Feb.
  34. Manchikanti L, Singh V, Falco FJ, Cash KA, Fellows B. Comparative Outcomes of a 2-Year Follow-Up of Cervical Medial Branch Blocks in Management of Chronic Neck Pain: A Randomized, Double-Blind Controlled Trial. Pain Physician. 2010 Sep-Oct.
  35. Manchikanti L, Staats PS, Singh V, Schultz DM, Vilims BD, Jasper JF, Kloth DS, Trescot AM, Hansen HC, Falasca TD, Racz GB, Deer TR, Burton AW, Helm S, Lou L, Bakhit CE, Dunbar EE, Atluri SL, Calodney AK, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Phys 2003; 6:3-81.
  36. Manchikanti, L., Singh, V., Kloth, D. Interventional Pain Management Practice Policies; Facet Joint Injections. American Society of Interventional Pain Physicians. Accessed 04/09/09.
  37. Narouze SN, Provenzano DA. Sonographically guided cervical facet nerve and joint injections: why sonography? J Ultrasound Med. 2013 Nov;32(11):1885-96. doi: 10.7863/ultra.32.11.1885.
  38. National Imaging Associates, Inc. Paravertebral Facet Joint Injections or Blocks Clinical Guideline, 2016.
  39. National Imaging Associates, Inc. Paravertebral Facet Joint Injections or Blocks Clinical Guideline, 2017.
  40. Nelemans PJ, de Bie RA, de Vet HCW, Sturmans F. Injection therapy for subacute and chronic benign low-back pain. The Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001824. DOI: 10.1002/14651858.CD001824.
  41. Obernauer J, Galiano K, Gruber H, Bale R, Obwegeser AA, Schatzer R, Loizides A. Ultrasound-guided versus Computed Tomography-controlled facet joint injections in the middle and lower cervical spine: a prospective randomized clinical trial. Med Ultrason. 2013 Mar;15(1):10-5.
  42. Park KD, et al. Effect of Medial Branch Block in Chronic Facet Joint Pain for Osteoporotic Compression Fracture: One Year Retrospective Study. Ann Rehabil Med 2013;37(2):191-201.
  43. Park SC, Kim KH. Effect of adding cervical facet joint injections in a multimodal treatment program for long-standing cervical myofascial pain syndrome with referral pain patterns of cervical facet joint syndrome. J Anesth. 2012 May 31.
  44. Resnick DK, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg: Spine 2:707–715, 2005.
  45. Rosenquist RW, Benzon HT, et al. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
  46. Santiago AE, Leal PC, Bezerra EH, Giraldes AL, Ferraro LC, Rezende AH, Sakata RK. Ultrasound-guided facet block to low back pain: a case report. Braz J Anesthesiol. 2014 Jul-Aug;64(4):278-80. doi: 10.1016/j.bjan.2012.09.005.
  47. Sukdeb D, Manchikanti L. It Is Time to Abandon Atlanto-Axial Joint Injections: Do No Harm! Anesthesiology: January 2011 - Volume 114 - Issue 1 - pp 222-224. Accessed at http://journals.lww.com/anesthesiology/Fulltext/2011/ on 08/21/13.
  48. Weiner, R. (2002). Pain Management A Practical Guide for Clinicians (6th ed). Boca Raton. CRC Press.
  49. Yun DH, et al. Effi cacy of Ultrasonography-Guided Injections in Patients with Facet Syndrome of the Low Lumbar Spine. Ann Rehabil Med 2012; 36: 66-71.
  50. Zakaria D, Skidmore B. Facet joint injection as a diagnostic and therapeutic tool for spinal pain: a review of clinical and cost effectiveness. Ottawa: Canadian Agency for Drugs and Technologies in Health (CADTH). 2007:28. Canadian Agency for Drugs and Technologies in Health (CADTH). (Accessed 08/21/12).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

02/15/04

New MCG created for Facet Joint Injections, separated from Outpatient Pain Management, 02-61000-01.

02/15/06

Review and revision of guideline consisting of updated references.

08/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

11/15/07

Review and revision of guideline consisting of updated references and addition of diagnosis codes.

05/15/09

Scheduled review; revise description section with addition of medical necessity management statement, update reimbursement guidelines, and update references.

09/15/09

Revision consisting of addition of a note to position statement for the use of steroid medications. Revise position statement to known or suspected facet joint pain. Clarify injections per date of service. Update limitations section.

01/01/10

Annual HCPCS Coding update: delete CPT codes 64470, 64472, 64475, & 64476. Add CPT codes 64490, 64491, 64492, 64493, 64494, & 64495. Revise description section, position statement, and reimbursement section. Add CPT instructions for codes 64491 – 64495.

04/15/10

Clarification added to reimbursement section regarding injection sets.

10/15/10

Revision; related ICD-10 codes added.

11/15/10

Revision; Certificate of Medical Necessity added; related ICD-10 codes added; guideline reformatted.

07/01/11

Revision; formatting changes.

08/15/11

Scheduled review; updated description section, CPT coding section, ICD9 and ICD10 coding sections; updated references; reformatted guideline.

10/15/12

Scheduled review. Maintained position statement; revised description and definitions; updated references and reformatted guideline.

10/15/13

Scheduled review. Revised position statement, CPT coding (added 0213T-0218T) and program exceptions section. Updated references.

07/01/15

Scheduled review. Revised description and position statement. Updated references.

10/01/15

Revision; updated ICD9 and ICD10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

08/15/16

Revision; updated ICD10 coding section.

04/15/17

Revision: updated criteria for facet joint injection and frequency of facet joint injection. Updated references.

Date Printed: June 28, 2017: 11:55 PM