Ultimate Guide to CPT Code 64490: Cervical & Thoracic Facet Joint Injection Billing (2026)
- Sirius solutions global
- 8 hours ago
- 5 min read
Why CPT Code 64490 Still Causes So Many Denials in 2026
If you work in pain management long enough, you have probably lived this moment.
The procedure went smoothly. Imaging confirmed the pain source. The cervical facet joint injection was placed exactly where it needed to be. The patient walked out feeling better than they had in months. Your team documented everything and sent the claim with confidence.
Then the denial arrives.
No matter how advanced billing systems become, CPT code 64490 continues to be one of the most closely scrutinized and frequently denied codes in pain management. Not because it’s rare or experimental, but because payers know it’s often billed incorrectly.
Overutilization concerns, strict Local Coverage Determinations (LCDs), evolving CMS rules, and modifier misuse have all turned facet joint injections into a compliance minefield. Even experienced practices lose revenue simply because one small detail was missed.
This guide exists to change that.
At Sirius Solutions Global, we work hands-on with pain management practices every day. We see the patterns behind denials, the documentation gaps payers flag, and the exact fixes that turn rejected claims into paid ones. This guide is built from that real-world experience not theory, not generic coding advice.
What CPT Code 64490 Actually Represents
According to the AMA, CPT code 64490 describes:
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level.
In practical terms, this code is used when a provider performs a facet joint or medial branch nerve injection in the cervical or thoracic spine, at one spinal level, using mandatory imaging guidance.
It can be diagnostic, therapeutic, or both but it must meet very specific criteria to be payable.
What CPT Code 64490 Includes and What It Does Not
Understanding what’s bundled into CPT 64490 is one of the most important steps in avoiding denials.
What’s Included
When you bill CPT code 64490, reimbursement already covers:
Diagnostic or therapeutic facet joint injections
Cervical or thoracic spine levels only
One spinal level (for example, C4–C5)
Fluoroscopy or CT imaging (required)
Injection of anesthetic and/or steroid
What You Should Never Bill Separately
Some of the most common denial triggers come from billing services that are already bundled into 64490, including:
Fluoroscopy guidance (77002, 77003)
CT guidance codes
Contrast injection codes
Separate imaging charges
Reality check: If imaging was used and it must be payment for that imaging is already built into CPT 64490. Billing it again is a fast track to denial or audit.
How the Procedure Is Performed (Why Payers Care)
From the payer’s perspective, CPT 64490 isn’t just about the injection it’s about precision.
The physician identifies the target facet joint or medial branch nerve under live fluoroscopy or CT. The needle placement is verified with imaging and contrast. Only then is the diagnostic anesthetic or therapeutic steroid injected.
Why does this matter for billing?
Because payers expect documentation to reflect this level of detail. If the note doesn’t clearly show imaging guidance, spinal level, and intent, medical necessity becomes difficult to defend even if the procedure itself was flawless.
CPT 64490 vs 64491 vs 64492: Where Practices Lose Money
One of the most common mistakes we see is billing CPT 64490 multiple times for multi-level injections.
Here’s the correct breakdown:
64490 – First cervical or thoracic level
64491 – Second level (add-on code)
64492 – Third level (add-on code)
Add-on codes cannot stand alone. They must always be reported alongside the primary code, 64490.
Repeating the primary code instead of using add-ons almost always leads to denial or downcoding.
Diagnosis Codes That Commonly Support CPT 64490
Correct CPT coding won’t save a claim if the diagnosis doesn’t support medical necessity.
Some of the most commonly accepted ICD-10 codes include:
M47.812 – Cervical spondylosis without myelopathy or radiculopathy
M47.814 – Thoracic spondylosis without myelopathy or radiculopathy
M54.2 – Cervicalgia
M54.6 – Thoracic spine pain
Always confirm which diagnoses are approved under your local MAC’s LCD. Coverage rules vary more than many practices realize.
Real-World Use Cases for CPT Code 64490
Cervical Spondylosis Without Neurological Deficits
A patient presents with chronic neck pain worsened by movement. Conservative treatments have failed. Imaging shows degenerative changes at C5–C6. A diagnostic facet joint injection is performed under fluoroscopic guidance.
This is a textbook example of CPT 64490 when paired with the appropriate diagnosis.
Therapeutic Facet Injection for Chronic Pain Relief
An older patient with documented facet arthropathy undergoes a therapeutic steroid injection at C4–C5. Imaging guidance is used, and functional limitations are documented.
Again, CPT 64490 applies when documentation supports it.
Modifiers That Make or Break CPT 64490 Claims
Modifiers are often the difference between payment and denial.
Modifier 50 – Used when injections are performed bilaterally at the same level
Modifier KX – Indicates medical necessity for additional diagnostic injections (Medicare)
RT / LT – Used by ASCs when billing bilateral procedures on separate lines
One important nuance: RT and LT modifiers should not be used outside the ASC setting.
Medicare Rules and Prior Authorization Requirements
Since July 1, 2023, CMS has required prior authorization for facet joint interventions performed in hospital outpatient departments.
This requirement does not apply to:
Physician offices
Ambulatory surgery centers
Critical access hospitals
Missing authorization in an HOPD setting almost always results in automatic denial no appeal, no exceptions.
CPT Code 64490 Reimbursement in 2026
Based on the Medicare Physician Fee Schedule:
Non-facility setting: Approximately $186
Facility setting: Approximately $102
Actual reimbursement varies by locality and MAC. At Sirius Solutions Global, we verify payer-specific rates before claims are submitted so there are no surprises after payment.
Documentation: Your Strongest Defense Against Denials
Strong documentation doesn’t just support payment it protects your practice during audits.
At minimum, CPT 64490 documentation should include:
Detailed pain history and failed conservative care
Imaging findings
Exact spinal level and laterality
Confirmation of imaging guidance
Medical necessity rationale
Patient response to prior injections
Physician signature and credentials
Incomplete or vague notes remain the leading cause of preventable denials.
The Most Common CPT 64490 Billing Mistakes We See
Across dozens of pain management practices, the same issues appear repeatedly:
Billing imaging separately
Repeating 64490 instead of using add-on codes
Missing the KX modifier
Using unsupported diagnosis codes
Skipping prior authorization in HOPD settings
Fixing these errors alone often improves approval rates within the first billing cycle.
Why Pain Management Practices Choose Sirius Solutions Global
Pain management billing isn’t generic and your billing partner shouldn’t be either.
At Sirius Solutions Global, we specialize in complex interventional procedures like facet injections, medial branch blocks, radiofrequency ablation, and epidural steroid injections.
Practices often compare us to companies like MediBillMD, AdvancedMD Billing, Kareo, and BellMedEx. What sets us apart is our procedure-level expertise, LCD tracking, and denial analytics built specifically for pain management.
Final Takeaway
CPT code 64490 isn’t difficult because it’s rare it’s difficult because it’s heavily regulated. When billed correctly, it’s a reliable revenue driver. When billed casually, it becomes a denial magnet.
With the right processes, documentation, and payer awareness, facet joint injections can be both clinically effective and financially predictable.
That’s exactly where Sirius Solutions Global helps practices succeed.
