Injection of anesthetic or steroid into a cervical or thoracic facet joint, or at the medial branch nerves supplying it, at a single level with imaging guidance.
- Medicare
- $205.08
- Work RVU
- 1.77
- Global, days
- 0
- Region
- Spine
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 3 cited references ↓
- Level and side injected, and whether joint or medial branch
- Whether the block is diagnostic or therapeutic
- Pre and post procedure pain scores for diagnostic blocks
- Duration of axial neck pain and the conservative care tried
- Imaging guidance used with a saved image
- Medication and volume injected
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 3 cited references ↓
64490 covers the first cervical or thoracic facet level injected in a session, whether the needle goes into the joint itself or onto the medial branches that supply it. Fluoroscopic or CT guidance is part of the code. A level means the joint, so a C5-6 medial branch block counts as one level even though two nerves get anesthetic.
Spine surgeons and PM&R physicians in ortho groups use it to confirm facet-mediated neck pain before radiofrequency ablation, or to treat it directly. Bilateral injections at the same level are one unit with modifier 50. The second and third levels go to 64491 and 64492.
Medicare contractors apply the facet joint interventions LCD. Expect requirements for at least three months of axial pain, failed conservative care, and pain that radiculopathy does not explain. Diagnostic blocks need recorded pain scores before and after, because the relief percentage decides whether RFA will be covered later. Payers also limit how often a region can be injected per year, so track session dates by region.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
Work RVU vs. total RVU
The work RVU (1.77) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (6.14) adds practice overhead and malpractice, and is what drives the Medicare payment below.
| Work RVU | 1.77 |
| Practice expense RVU | 4.2 |
| Malpractice RVU | 0.17 |
| Total RVU | 6.14 |
| Medicare national rate | $205.08 |
| Global period | 0 days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $205.08 |
HOPD (APC 5443) Hospital outpatient department | $903.63 |
ASC (PI G2) Ambulatory surgical center (freestanding) | $485.51 |
Common denial reasons
The recurring reasons claims for CPT 64490 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Frequency limit exceeded for the cervical region in a rolling 12 months
- Missing documentation of at least three months of pain and failed conservative care
- Imaging guidance billed separately
- Same-day epidural injection in the same region without supporting documentation
- Diagnosis does not support facet-mediated pain
- Bilateral billed as two units instead of modifier 50
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 3 cited references ↓
01Does 64490 include fluoroscopy?
02Is a medial branch block billed with the same code as an intra-articular facet injection?
03How do you bill bilateral cervical facet injections?
04How much relief is needed after a diagnostic medial branch block?
Sources & references
Editorial content was developed using the following public sources.
Mira Scribe
Mira Scribe notes capture the axial pain history, prior therapy, and the pre and post block pain scores in plain language, which is what reviewers look for when a facet block or later RFA is questioned.
See how Mira captures CPT 64490 documentation