Coding and Documentation Tips for Spinal Injections

Mary LeGrand, RN, MA, CCS-P, CPC

In recent years, the American Medical Association’s Current Procedure Terminology (CPT) deleted the mainstay facet joint injection codes (64475–64479) and introduced the “all-inclusive” paravertebral facet joint injection codes 64490–64495. These new codes are part of the transition from component coding to the combination codes. Understanding the code changes, when services can be reported independently, and when the new combination codes must be used is critical.

Steps to coding spinal injections
The following steps should be taken in coding spinal injections:

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