CPT 64490: Facet Joint Injection
CPT 64490: Facet Joint Injection, Explained
CPT 64490 covers an injection into the first facet joint level in the cervical or thoracic spine, used to diagnose or treat facet-joint-related pain.
What is CPT 64490?
64490 reports an injection of anesthetic and/or steroid into a cervical or thoracic facet joint (or the nerves supplying it), at a single level, including imaging guidance. It’s part of a family of facet injection codes covering different spinal regions and additional levels, make sure the level and region documented in the procedure note matches the specific code billed.
When to use it
Use 64490 for the first cervical or thoracic facet joint level injected in a session, typically for a patient with suspected or confirmed facet-joint-mediated pain, often as a diagnostic step before considering a longer-term intervention. Imaging guidance is required and must be documented.
Medicare generally limits facet joint injections to 4 per joint per year. This is a frequency limit that’s easy to lose track of across a busy practice, especially when a patient sees multiple providers, without a system tracking it per patient and per joint, it’s a common source of avoidable denials.
What your documentation needs to show
The note needs to specify the exact spinal level and side injected, the imaging guidance method used, and the clinical rationale, typically the patient’s pain pattern, prior conservative treatment, and why a facet injection is appropriate. If performed bilaterally at the same level, that needs to be clearly documented, since it affects how modifier 50 should be applied.
Common reasons this code gets denied
Exceeding frequency limits. Going past the typical 4-per-joint-per-year Medicare cap without documentation that clearly supports the additional injections.
Missing or incorrect modifier 50. For bilateral injections at the same level, modifier 50 needs to be applied correctly, a frequent and avoidable error.
Level or region mismatch. Billing 64490 when the documented procedure was actually at a different spinal region or level than the code describes.
Incomplete imaging documentation. Since imaging guidance is required, a note that doesn’t clearly document it can result in denial regardless of whether the procedure was performed correctly.
Related codes
Frequently asked questions
How many facet joint injections will Medicare cover? +
Generally 4 per joint per year. Going over that without clear documented justification is a common and avoidable reason for denial.
Does 64490 require imaging guidance? +
Yes, imaging guidance is required and needs to be clearly documented in the procedure note.
What if the injection is performed on both sides? +
Bilateral injections at the same level need modifier 50 applied correctly. Missing or misapplying it is one of the most frequent reasons these claims get kicked back.
Seeing denials on facet injection claims?
We work specifically with pain management practices. A free audit looks at your actual claims and shows you exactly what’s behind your denial pattern, not a generic checklist.