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Anesthesia Coding Alert

READER QUESTIONS:

Document Before Adding 51 to Epi Injection

Published on Wed Jul 20, 2005

Question: Our physician administered two mid-line lumbar epidural injections at different levels. Should we report a modifier with the second level?


New Mexico Subscriber


Answer: Code the injection with 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).
 
Administering multiple epidural injections during the same session is unusual, so expect the carrier to examine the claim carefully.

Some carriers might not pay for more than one epidural injection per day. If you determine that the second injection is billable and can be medically justified, append modifier 51 (Multiple procedures) to the second injection's code.
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