Focused Neurological / Musculoskeletal Exam -Facet Joint Inj

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fjohnson
Posts: 59
Joined: Wed Mar 13, 2013 9:04 am

Tue Aug 07, 2018 10:13 am

Has anyone found specific requirements of what a focused neurological or musculoskeletal exam to support this component of facet joint injections, CPT codes 64490 - 64495 & 64633 - 64636?
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admin
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Posts: 431
Joined: Mon Apr 09, 2012 1:54 pm

Mon Aug 20, 2018 9:34 am

Hello!

The word 'focused' indicates that the exam findings prior to the decision to perform the procedures are going to primarily be musculoskeletal and neurological findings. This is not to say it is inappropriate for other organ systems to be documented, but the expectation would be that most of the exam would fall in one of these two systems. We can use the 1997 Documentation Guidelines to identify the types of findings these may include. (This is not a suggestion to audit them in ’97, just to use them as a reference tool). The documentation of these systems would be pertinent to the presenting problem at the clinical judgement of the provider. The exam examples we are given are:

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Your question has been answered by Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA
fjohnson
Posts: 59
Joined: Wed Mar 13, 2013 9:04 am

Mon Aug 20, 2018 1:28 pm

Thank you.
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