64628
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
6.97
Facility
$364.74
Non-Facility
$364.74
Documentation Required
- Medical records must document the specific vertebral bodies treated and that imaging guidance was used; coding must reflect number of vertebral bodies treated (first two = 64628; each additional = 64629).
- Claims and coding should follow the referenced Local Coverage Determination L39420 and this billing/coding guidance article.
- Affix the -KX modifier to the covered CPT code to indicate identification of Modic 1 or 2 changes in the treated vertebral body and absence of prior BVN ablation.
- The medical record must include the performing provider's assessment (complete history and physical exam) related to the patient's complaint.
Key Coverage Criteria
- Thermal destruction (ablation) of the intraosseous basivertebral nerve (BVN) is a billing/coding procedure for treatment of vertebrogenic lower back pain per Local Coverage Determination L39420.
- Report CPT 64628 for thermal destruction of the intraosseous basivertebral nerve for the first two vertebral bodies with imaging guidance in the lumbar or sacral spine.
- Report CPT 64629 for each additional vertebral body (lumbar or sacral) treated; include all imaging guidance and list 64629 separately in addition to the primary procedure.
- Ablation of the intraosseous basivertebral nerve (BVN) is covered only when performed within vertebral bodies L3 through S1.
- Coverage requires documented Modic type 1 OR Modic type 2 changes within the specific vertebral body targeted for treatment.
- Coverage requires absence of any prior BVN ablation to the named vertebral body being treated.
19 Active Policies
AMBETTER-CP.MP.170 — Nerve Blocks and Neurolysis for Pain Management
A59205 — Billing and Coding: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain
A59466 — Billing and Coding: Intraosseous Basivertebral Nerve Ablation
A59468 — Billing and Coding: Intraosseous Basivertebral Nerve Ablation
L39420 — Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain
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