Medial Nerve Block L3,L4 and L5

How would we code below procedure.  Bilateral diagnostic medial branch nerve block of  The L3, L4 medial branch nerve and L5 dorsal ramus ?  64493-50, 64494-50 and 64495?  Or would we bill 64493-50, 94494-50 and 64450 for the dorsal ramus?thanks in advance for your help

re: Medial Nerve Block L3,L4 and L5

There are a few places to look for your answers, the Medicare Physician Fee Schedule (MPFS) Indicators and the CPT guidelines, first let’s look at the MPFS.

Medicare assigns each Code a fee schedule indicator stating how the code will be paid. Since modifiers 50 and 51 impact payment, they are assigned an indicator. This can be found on Find-A-Code under Additional Code Information, or it may also be searchable on CMS.gov. 

Let’s look at the codes in question.

CPT Code Description Modifier 51

• Multiple Modifier 51 is allowed Modifier 50


• Bilateral Modifier 50 is allowed 64493 lumbar or sacral; single level 2


• Standard payment adjustment rules for multiple procedures apply.


• Yes 1-150% payment adjustment for bilateral procedures applies.


• Yes 64464  lumbar or sacral; second level (List separately in addition to code for primary procedure) multiple procedures 0


• No payment adjustment rules for multiple procedures apply.


• NO 1 - 150% payment adjustment for bilateral procedures applies.


• Yes 64495 lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 0 - No payment adjustment rules for multiple procedures apply. NO 1 - 150% payment adjustment for bilateral procedures applies. Yes What does Payment indicator # 1 tell us? According to CMS, “150 percent payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g.‚ with RT and LT modifiers or with a 2 in the units field)‚ base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code. If code is reported as a bilateral procedure and is reported with other procedure codes on the same day‚ apply the bilateral adjustment before applying any applicable multiple procedure rules.” Now we know these codes are payable at a different rate and let’s take a look at the CPT guidelines on how to correctly report the CPT codes.  CPT states; “(For bilateral paravertebral facet injection procedures, report 64490, 64493 with modifier 50. Report add-on codes 64491, 64492, 64494, and 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495)"Depending on the payer requirements, report the codes with RT/LT modifiers or report them with 2 units, I have found there is more room for error if you only report 2-units, so anytime you can, I suggest adding an additional line item, in other words, using Rt and LT modifiers.  64493-50, 64494-LT, 64494-RT, 64495-LT, 64495-RT