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Winter 2009

The Government is Watching Facet Joint Injection Claims

Cathy Reifer, CPC
Regional Director of Client Services, ABC

According to a report issued by the HHS Office of the Inspector General (OIG) on September 17, 2008 (, 63% of all claims for facet joint injections submitted to Medicare in 2006 were coded incorrectly. The report goes on to state that the miscoding resulted in Medicare’s overpaying approximately $96 million.

The publication of this report serves to remind anesthesiologists and pain specialists that this is a potential high risk area for “fraud and abuse.” You should be paying close attention to the way your practice is billing and documenting facet joint injections. Be completely familiar with the Medicare carrier policies (Local Coverage Determinations) for these procedures.

We can expect that the OIG’s efforts have also alerted private payers to the potential for preventing and recovering some payments for these procedures. Heightened caution is in order across the board – especially if the services are provided in private office settings, where more billing errors were found than in hospitals or ambulatory surgical centers. Make sure that you have copies of any applicable private payer policies on facet joint and other pain medicine injections.

Common Errors in Documentation

  • Lack of documentation, either missing altogether, or lacking a description of the procedure performed
  • Missing key details such as cervical or lumbar levels
  • Insufficient documentation to support the diagnosis and demonstrate medical necessity
  • Know the Rules for Bilateral Procedures

Both the cervical facet joint injection code, CPT™ 64470, and the lumbar code, 64475, are for single level injections. Codes 64442 and 64476 are the respective add-ons for each additional level. Using multiple lines of the add-on codes instead of modifier 50, which designates bilateral services, yields a 50% overpayment.

  • 64470 and 64475 are primary codes
  • 64470 and 64475 are unilateral procedures
  • 64472 and 64476 (each additional level) are add on codes
  • Can not bill independent of primary code
  • Paravertebral facet joint injection coding is per facet joint NOT number of needles inserted (CPT Assistant September 2004)
  • Multiple surgery rules apply to primary codes, not add-on codes

By paying careful attention to this area of heightened OIG scrutiny, you will be better able to prevent any unwanted attention from governmental or private payers.