Neurology & Pain Management Coding Alert

Question: The physician documented that he administered transforaminal epidurals to L4/L5 and L5/S1. Am I correct in coding it twice?

Arizona Subscriber

Answer:  Code the L4-L5 injection with 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level). Add-on code 64484 (… lumbar or sacral, each additional level [List separately in addition to code for primary procedure]) represents the L5-S1 injection.

Remember: A spinal segment is composed of two vertebrae, the intervertebral disc between them, and the two nerve roots that exit from that spinal level, one from each side. For example, L4-L5 makes up one spinal segment/level with the L4 spinal nerve exiting at that level, while the L5 spinal nerve exits at the L5-S1 spinal level. Choose the codes based on spinal level. Begin with 64479 (… cervical or thoracic, single level) or 64483 for the first level injected and include 64480 (… cervical or thoracic, each additional level [List separately in addition to code for primary procedure]) or 64484 for additional levels. Bilateral injections are not considered to be injections at two spinal levels; rather they are bilateral injections of a single level.  Bilateral injections should be billed with modifier 50 to indicate the bilateral service rather than one of the corresponding add-on codes.

Guidance change: Note that codes 64483 and 64479 specify fluoroscopic or CT guidance. If your provider uses ultrasound guidance instead, report 0228T (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level) or 0230T (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level). The associated add-on codes for additional levels are +0229T for cervical/thoracic and +0231T for lumbar/sacral.