Outpatient Facility Coding Alert
Circumstances Help Dictate Whether You Can Submit 72275 With 64479
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Question: I am a coder working with a pain clinic. Could I charge for 72275 along with the code 64479 for transforaminal cervical injections?
Kentucky Subscriber
Answer: Code 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level) is used for injection of an anesthetic agent and/or steroid in the form of a transforaminal epidural into a single level (either cervical or thoracic) with fluoroscopic or CT imaging guidance. CPT(R) code 72275 (Epidurography, radiological supervision and interpretation) is used only when the physician performs an epidurogram, documents the resulting images, and writes a formal radiologic report.
Since 72275 is a component of 64479 (according to Correct Coding Initiative edits), if you have documentation that the physician completed the requirements of an epidurogram at a separate session from the injection, you can code for both procedures. If he doesn’t perform an epidurogram during a separate session or doesn’t have all the supporting documentation, you can only report 64479.
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