Radiology Coding Alert

Use this CPT^® Assistant article as your guiding reference.

If the process of coding pain management techniques involving the spine is leaving you in your own world of hurt, you’re not alone. Discerning between the varying code sets of spinal injection services is a process that can only be mastered with time and experience.

“Detailed provider documentation is also key to successful spinal injection coding, so clinical documentation improvement [CDI] efforts may need to be employed,” states Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina. Fortunately, we’re here to kickstart the process by getting you acclimated to each nuanced code set.

As you’ll see, to master the art of spinal injection coding, there are four sets of CPT® codes with which you have to be intimately familiar. Keep reading for a detailed breakdown of two of these code sets — including everything you need to know to be a confident and successful spinal pain management coder.

Break Down Each Respective Procedure

First, have a look at these two code sets for transforaminal injections and paravertebral block injections, respectively:

Transforaminal injection:

• 64479 — Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
• +64480 — … each additional level (List separately in addition to code for primary procedure)
• 64483 — … lumbar or sacral, single level
• +64484 — … each additional level (List separately in addition to code for primary procedure).

Paravertebral block:

• 64461 — Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
• +64462 — … second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure)
• 64463 — … continuous infusion by catheter (includes imaging guidance, when performed).

I.D. CPT^® Assistant Guidelines and Notes

Volume 26, Issue 1 of the 2016 CPT^® Assistant conveniently breaks down the differences between these two services. First, have a look at CPT^® Assistant’s main bullet points for code set (64479-+64484):

• “Needle only. Catheters are not used for transforaminal injections.
• “Requires a needle to be placed along the transverse process of the vertebra to deliver drugs into the epidural space via the foramen.”
• “Includes imaging guidance using CT or fluoroscopy.
• “The injection volume is less than PVB and is intended to block a single nerve within the epidural space.”

Additionally, CPT^® Assistant notes how and why payers and providers consider transforaminal injections to be more extensive than their paravertebral block and interlaminar epidural injection counterparts:

• “Since the vertebral artery (in the cervical spine), radiculomedullary arteries, as well as the spinal cord are in close proximity to the nerve root, this procedure involves a much higher risk with more work than a translaminar epidural injection.”

Next up, see how CPT^® Assistant contrasts the (64461-64463) paravertebral block code set from that of the transforaminal code set:

• “May be performed with either a needle for single injections or a catheter for infusions.
• “Requires a needle to be placed lateral to the vertebral body beyond and anterior to the transverse process, outside the neuraxial canal to affect the nerves at the point of exit from the neural foramen.
• “Includes imaging guidance of any type, including ultrasound.
• “The injection volume is greater than transforaminal injection and is intended to block several nerves at the point of exit from the spinal column.”

As you can see, the underlying differences relate to method of injection, imaging, needle/catheter placement, and the number of nerves being blocked. CPT^® Assistant further elaborates on the process of the paravertebral block injection with the following in-depth description:

• “A PVB is achieved by the administration of local anesthetic into the paravertebral area as a single injection, multiple injections, or continuous infusion at any level of the thoracic spine. A PVB targets the sympathetic chain of nerves and somatic nerves (intercostal and spinal nerves and their branches), which may be utilized for dermatomal coverage from T2 (thoracic level 2) to L1 (lumbar level 1). PVBs are used for postoperative pain control and thoracic and abdominal wall analgesia (for example, to treat pain after a thoracotomy or a mastectomy), or for multiple rib fracture analgesia (whether or not surgical intervention is needed).”

Differentiate Services, Hone in on These 2 Examples

One of the most common questions coders experience when distinguishing these two services is where, specifically, the needle injection placements differ. Use these two operative report examples to help elaborate on the differences.

Example: The paravertebral space between the third and fourth thoracic vertebrae is identified in a parasagittal view approximately 3 cm lateral to midline on the side of surgery. A local anesthetic skin wheal is raised caudal to the ultrasound transducer. Then, a regional block needle is inserted through the skin wheal in plane beneath the ultrasound transducer and directed to the paravertebral space.

In this example, there are a few keywords to pinpoint in making the proper coding determination. First, you can see the provider identifies the paravertebral space between the third and fourth thoracic vertebrae. Next, the provider documents the use of ultrasound imaging during the injection process. Based on the information above, you should be able to confidently determine that this surgical procedure perfectly aligns with the paravertebral block (64461-64463) code set. Specifically, code 64461 since the provider documents a single needle injection.

Example: Under intravenous anesthetic, the affected foramen is identified and the skin is infiltrated with local anesthetic. A needle is directed lateral to midline under fluoroscopic guidance into the cervical foramen. Both anteroposterior and oblique views are needed to get depth as well as anterior and posterior position. Contrast injection is performed to confirm needle tip location. After this is completed, anesthetic agent and/or steroid is injected. The injection needle is removed, and dressing is applied.

With this example, you have enough information to determine that you should report a code from the transforaminal epidural injection code set (64479-+64484). First, you see that the provider documents a needle injection using fluoroscopic guidance. Additionally, the needle placement into the foramen to reach the epidural space falls in accordance with the CPT^® Assistant guidelines on transforaminal injection coding referenced above. Since the provider documents a single level the cervical spine, you will report code 64479.

After covering these two difficult code sets, you should feel more confident in your transforaminal injection and paravertebral block coding down the road — but the challenge of spinal injection coding isn’t over yet. Stay tuned for a future issue of Radiology Coding Alert, in which we will cover two additional spinal injection code sets (64490-+64495 and 62320-62327).