CPT Code 64494: Complete 2026 Guide to Description, Billing & Usage

CPT 64494 is the add-on code for the second lumbar or sacral facet joint level treated in the same session. It never stands alone. It rides with 64493, and most denials come from three mistakes: billing it as a primary code, counting nerves instead of levels, or missing the documentation that Medicare's facet joint policy asks for. If your pain management claims keep stalling on facet injections, this guide shows where they go wrong.

Quick answer: Report 64494 once for the second lumbar or sacral facet level injected, always on the same claim as 64493 for the first level. Use 64495 for the third and any further levels. Fluoroscopic or CT guidance is included, so do not bill imaging separately. For a bilateral procedure, Medicare expects modifier 50 on each line with one unit.

What Is CPT Code 64494?

CPT 64494 describes an injection of a diagnostic or therapeutic agent into a paravertebral facet (zygapophyseal) joint, or into the nerves that supply it, at a second lumbar or sacral level, with fluoroscopic or CT guidance. It covers both intra-articular injections and medial branch blocks. It is listed separately in addition to the primary code, 64493.

The facet injection code family

What counts as a level? A level is one facet joint, such as L4–L5. Blocking the medial branches that supply the L4–L5 joint still counts as one level, even though two nerves are injected. Billing 64494 for the second nerve of the same joint is one of the most common overcoding errors in facet claims.

What the code includes

• Image guidance with fluoroscopy or CT. Do not report 77003 or 77012 separately.
• Both intra-articular facet injections and medial branch blocks at that level.
• The injectate, whether anesthetic, steroid or both.

Ultrasound-guided facet injections are reported with Category III codes instead: 0213T–0215T for cervical or thoracic and 0216T–0218T for lumbar or sacral. Confirm coverage before scheduling, because many payers treat these codes as investigational.

How to Bill 64494 Correctly

1. Confirm the region. 64494 is for lumbar or sacral levels only. Cervical and thoracic work goes to 64490–64492.
2. Count distinct joints. One joint is one level, whichever technique was used.
3. Report the primary code first. 64493 goes on line one, 64494 on line two, and 64495 for any further level.
4. Handle laterality. For Medicare, add modifier 50 with one unit when both sides are done at the same level. Some commercial payers want RT and LT on separate lines, so check the payer's policy.
5. Link the right diagnosis. Point each line to the facet-related diagnosis that supports medical necessity.

Coding scenarios

Which Modifiers Apply to CPT 64494?

Before you add any modifier, check the code pair in the CMS National Correct Coding Initiative edits. If the pair does not allow a modifier, the claim will deny no matter what you append.

What Does Medicare Require for Facet Injections?

Medicare Administrative Contractors use the local coverage determination "Facet Joint Interventions for Pain Management". Each MAC publishes it under its own number, such as LCD L38773. The policy is detailed, so read your MAC's current version. These are the points practices most often miss:

• Duration and conservative care: Chronic axial pain for at least three months, with documented failure of conservative treatment.
• Pain and function scores: Baseline pain and functional impairment recorded before the procedure, and response recorded after it.
• Diagnostic blocks before ablation: Two diagnostic medial branch blocks, each with at least 80% relief, before radiofrequency ablation is covered.
• Session and level limits: Caps on sessions per rolling 12 months for each spinal region, and generally no more than two levels per session.
• Guidance: Fluoroscopy or CT. Ultrasound-guided facet procedures are not covered under the LCD.

Repeat therapeutic injections are where audits focus. If the note does not show the relief from the last injection and how long it lasted, the next claim is at risk, even when the procedure itself was coded correctly.

Diagnosis Codes Commonly Paired With 64494

Payers publish their own covered diagnosis lists in the LCD billing article, and many do not accept unspecified low back pain alone. Code to the facet pathology documented in the note. Our medical coding team reviews these pairings before claims go out.

Documentation Checklist for 64494

• Levels treated, named by joint (for example L4–L5 and L5–S1), and side.
• Technique: intra-articular injection or medial branch block.
• Guidance used, with a saved image showing needle placement.
• Drug, dose and volume at each level.
• Pre- and post-procedure pain scores and functional status.
• Response to any prior injection and how long relief lasted.
• Conservative treatment tried and its outcome.

Why Do 64494 Claims Get Denied?

If 64494 denials are already on your books, our guides on recovering denied pain management claims and increasing collections in pain management billing walk through the appeal steps. Persistent patterns are usually a front-end problem that denial management can trace to its source.

Conclusion

CPT 64494 FAQs