How To Use CPT Code 64491

CPT 64491 is an add-on code for injecting diagnostic or therapeutic agents into paravertebral facet joints or nerves innervating those joints with image guidance at the cervical or thoracic level. This article will cover the description, procedure, qualifying circumstances, when to use, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 64491.

1. What is CPT 64491?

CPT 64491 is an add-on code used to report the injection of diagnostic or therapeutic agents into paravertebral facet joints or nerves innervating those joints with image guidance at the cervical or thoracic level. This code is specifically used for the second level of injection, after an initial separately reportable injection. The purpose of this procedure is to treat spinal pain or identify the exact source of pain.

2. 64491 CPT code description

The official description of CPT code 64491 is: “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)”.

3. Procedure

The 64491 procedure involves the following steps:

1. Administering facet injections at an initial spinal level.
2. Prepping and anesthetizing the patient for a second cervical or thoracic level facet joint injection.
3. Inserting the needle through the skin and advancing it to the proper position within the joint using either fluoroscopy or CT imaging guidance.
4. Injecting the therapeutic or diagnostic agent, such as a steroid or anesthetic mixture.
5. Removing the needle and ensuring that the site obtains hemostasis.

4. Qualifying circumstances

Patients eligible to receive CPT code 64491 services are those experiencing spinal pain or requiring identification of the exact source of pain. The provider must determine that the patient requires a second level of injection at the cervical or thoracic level, following an initial separately reportable injection. The patient must also be able to tolerate the procedure and any potential risks associated with the injection.

5. When to use CPT code 64491

It is appropriate to bill the 64491 CPT code when the provider performs a second level of injection at the cervical or thoracic level, following an initial separately reportable injection. This code should be used in conjunction with the primary code for the initial injection (CPT 64490) and any additional levels (CPT 64492). The provider must use image guidance, either fluoroscopy or CT, during the procedure.

6. Documentation requirements

To support a claim for CPT 64491, the following information must be documented:

• Patient’s medical history and symptoms indicating the need for the procedure.
• Details of the initial injection, including the primary code (CPT 64490) and the specific spinal level.
• Details of the second level injection, including the spinal level and the type of image guidance used (fluoroscopy or CT).
• Type and dosage of the diagnostic or therapeutic agent injected.
• Any complications or adverse reactions experienced by the patient during or after the procedure.
• Outcome of the procedure, including any pain relief or identification of the pain source.

7. Billing guidelines

When billing for CPT code 64491, keep in mind the following guidelines:

• Report CPT 64491 as an add-on code in addition to the primary code for the initial injection (CPT 64490).
• Use CPT 64491 for the second level of injection and CPT 64492 for the third and any additional levels.
• Do not report CPT 64491 more than once per day.
• Do not separately report imaging guidance, specifically fluoroscopy or CT.

8. Historical information

CPT 64491 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Similar codes to CPT 64491

Five similar codes to CPT 64491 and how they differentiate are:

• CPT 64490: Used for the initial cervical or thoracic level injection, rather than the second level.
• CPT 64492: Used for the third and any additional cervical or thoracic level injections, rather than the second level.
• CPT 64493: Used for the initial lumbar or sacral level injection, rather than the cervical or thoracic level.
• CPT 64494: Used for the second lumbar or sacral level injection, rather than the cervical or thoracic level.
• CPT 64495: Used for the third and any additional lumbar or sacral level injections, rather than the cervical or thoracic level.

10. Examples

Here are 10 detailed examples of CPT code 64491 procedures:

1. A patient with chronic neck pain receives an initial injection at the C3-C4 level (CPT 64490) and a second injection at the C4-C5 level (CPT 64491) using fluoroscopy guidance.
2. A patient with thoracic pain undergoes an initial injection at the T5-T6 level (CPT 64490) and a second injection at the T6-T7 level (CPT 64491) using CT guidance.
3. A patient with cervical radiculopathy receives an initial injection at the C6-C7 level (CPT 64490) and a second injection at the C7-T1 level (CPT 64491) using fluoroscopy guidance.
4. A patient with thoracic facet joint pain undergoes an initial injection at the T2-T3 level (CPT 64490) and a second injection at the T3-T4 level (CPT 64491) using CT guidance.
5. A patient with cervical spondylosis receives an initial injection at the C5-C6 level (CPT 64490) and a second injection at the C6-C7 level (CPT 64491) using fluoroscopy guidance.
6. A patient with thoracic disc herniation undergoes an initial injection at the T7-T8 level (CPT 64490) and a second injection at the T8-T9 level (CPT 64491) using CT guidance.
7. A patient with cervical spinal stenosis receives an initial injection at the C4-C5 level (CPT 64490) and a second injection at the C5-C6 level (CPT 64491) using fluoroscopy guidance.
8. A patient with thoracic degenerative disc disease undergoes an initial injection at the T9-T10 level (CPT 64490) and a second injection at the T10-T11 level (CPT 64491) using CT guidance.
9. A patient with cervical osteoarthritis receives an initial injection at the C3-C4 level (CPT 64490) and a second injection at the C4-C5 level (CPT 64491) using fluoroscopy guidance.
10. A patient with thoracic spondylolisthesis undergoes an initial injection at the T11-T12 level (CPT 64490) and a second injection at the T12-L1 level (CPT 64491) using CT guidance.