Add-on for a second cervical or thoracic facet joint or medial branch level injected during the same session, with imaging guidance included.
- Medicare
- $101.87
- Work RVU
- 1.13
- Global, days
- 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 ↓
- Both levels injected, identified by joint
- Side for each level
- Diagnostic or therapeutic intent
- Imaging guidance with saved images
- Pain scores before and after for diagnostic blocks
- Medication and volume at each level
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 ↓
64491 is billed once for the second cervical or thoracic facet level in a session and only alongside 64490. It is an add-on with a ZZZ global, so it carries no separate global period and no multiple procedure reduction.
A common ortho scenario is a diagnostic medial branch block at C4-5 and C5-6 for a patient with chronic neck pain and degenerative facets on CT. 64490 goes to the first level, 64491 to the second. If both levels are done on both sides, each code takes modifier 50.
The frequent mistake is billing 64491 with two units to cover a bilateral second level, or using it for a lumbar level. Lumbar levels have their own codes (64493 to 64495). Medicare facet LCDs limit the number of levels per session, so check the policy before adding a third. Imaging guidance stays bundled, and the same frequency limits on the region apply to the whole session.
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 (1.13) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (3.05) adds practice overhead and malpractice, and is what drives the Medicare payment below.
| Work RVU | 1.13 |
| Practice expense RVU | 1.81 |
| Malpractice RVU | 0.11 |
| Total RVU | 3.05 |
| Medicare national rate | $101.87 |
| Global period | 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 | $101.87 |
Common denial reasons
The recurring reasons claims for CPT 64491 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Billed without 64490 on the same date
- Two units billed to represent bilateral injection
- Lumbar level coded with the cervical add-on
- Levels per session exceed LCD limits
- Frequency limit for the region exceeded
- Medical necessity documentation missing for the second level
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 3 cited references ↓
01Can 64491 be billed alone?
02Is 64491 billed with modifier 50 for bilateral?
03Can 64491 be used for lumbar facet injections?
Sources & references
Editorial content was developed using the following public sources.
Mira Scribe
Mira Scribe notes list each injected level and side clearly, so the coder can match 64490 and 64491 to the exact joints without guessing.
See how Mira captures CPT 64491 documentation