How To Use CPT Code 64495

CPT 64495 refers to the injection of a diagnostic or therapeutic agent into a paravertebral facet joint or nerves innervating that joint, with image guidance, at the lumbar or sacral level. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 64495 procedures.

1. What is CPT 64495?

CPT 64495 is a medical billing code used to describe a specific type of injection procedure performed on the paravertebral facet joint or nerves innervating that joint, at the lumbar or sacral level. This procedure involves the use of image guidance, such as fluoroscopy or CT, to ensure accurate placement of the injection. The purpose of this procedure is to treat spinal pain or identify the exact source of pain.

2. 64495 CPT code description

The official description of CPT code 64495 is: “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)”.

3. Procedure

The 64495 procedure involves the following steps:

1. The patient is prepped and anesthetized for the third and any additional level facet joint injections.
2. The provider inserts the needle through the skin and advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance.
3. The provider injects the therapeutic or diagnostic agent, such as a steroid or anesthetic mixture.
4. The needle is removed, and the provider ensures that the site obtains hemostasis.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 64495 services are those experiencing spinal pain or requiring identification of the exact source of pain. This procedure is typically performed after facet injections at two initial spinal levels, with CPT 64495 being used for the third and any additional levels. The injections must be performed at the lumbar or sacral level of the spine.

5. When to use CPT code 64495

It is appropriate to bill the 64495 CPT code when the provider has performed facet joint injections at two initial spinal levels and is performing the third and any additional level injections during the same session. The injections must be performed at the lumbar or sacral level, and the provider must use image guidance, such as fluoroscopy or CT, to ensure accurate placement of the injection.

6. Documentation requirements

To support a claim for CPT 64495, the following information should be documented:

• Patient’s medical history and symptoms indicating the need for the procedure
• Details of the two initial facet joint injections, including the spinal levels and the CPT codes used
• Description of the third and any additional level injections, including the spinal levels, the type of diagnostic or therapeutic agent used, and the image guidance method employed
• Outcome of the procedure, including any pain relief or identification of the pain source
• Any complications or adverse reactions experienced by the patient

7. Billing guidelines

When billing for CPT code 64495, it is important to remember that it is an add-on code and must be reported in conjunction with the appropriate primary code, 64493. Report 64493 for the initial lumbar or sacral level, +64494 for the second level, and +64495 for the third and any additional levels. CPT 64495 may not be reported more than once per day, and imaging guidance, specifically fluoroscopy or CT, should not be reported separately.

8. Historical information

CPT 64495 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 64495

Five similar codes to CPT 64495 and how they differentiate are:

• CPT 64490: Describes the injection procedure for the first cervical or thoracic level
• CPT 64491: Describes the injection procedure for the second cervical or thoracic level
• CPT 64492: Describes the injection procedure for the third and any additional cervical or thoracic levels
• CPT 64493: Describes the injection procedure for the first lumbar or sacral level
• CPT 64494: Describes the injection procedure for the second lumbar or sacral level

10. Examples

Here are 10 detailed examples of CPT code 64495 procedures:

1. A patient with chronic lower back pain receives facet joint injections at L4-L5 and L5-S1 levels, followed by a third injection at the L3-L4 level using CPT 64495.
2. A patient with sciatica undergoes facet joint injections at S1-S2 and L5-S1 levels, and a third injection at the L4-L5 level using CPT 64495.
3. A patient with lumbar spinal stenosis receives facet joint injections at L3-L4 and L4-L5 levels, followed by a third injection at the L2-L3 level using CPT 64495.
4. A patient with degenerative disc disease undergoes facet joint injections at L5-S1 and L4-L5 levels, and a third injection at the L3-L4 level using CPT 64495.
5. A patient with spondylolisthesis receives facet joint injections at L4-L5 and L3-L4 levels, followed by a third injection at the L2-L3 level using CPT 64495.
6. A patient with lumbar radiculopathy undergoes facet joint injections at L5-S1 and L4-L5 levels, and a third injection at the L3-L4 level using CPT 64495.
7. A patient with sacroiliac joint dysfunction receives facet joint injections at L5-S1 and S1-S2 levels, followed by a third injection at the L4-L5 level using CPT 64495.
8. A patient with lumbar facet joint syndrome undergoes facet joint injections at L4-L5 and L3-L4 levels, and a third injection at the L2-L3 level using CPT 64495.
9. A patient with lumbar spondylosis receives facet joint injections at L5-S1 and L4-L5 levels, followed by a third injection at the L3-L4 level using CPT 64495.
10. A patient with lumbar disc herniation undergoes facet joint injections at L4-L5 and L5-S1 levels, and a third injection at the L3-L4 level using CPT 64495.