Test your coding knowledge. Determine how you would code this situation before looking at the box below for the
answer. Question: When coding for an epidural steroid injection, for the epidurography we bill 72275 (Epidurography, radiological supervision and interpretation). For the injection of Marcaine into the epidural space, should we use 64483 or 62311? Doesn't the injection of the steroid need to specify that it was a transforaminal approach in order to use 64483? The contrast is not what the 6-code represents, so I am wondering if I would be upcoding if I still put transforaminal/64483, especially because the title and the main injection code do not specify this. Florida Subscriber Answer: The answer to this set of questions depends on the exact description of what service(s) was provided. The code for epidurography is typically not assigned in addition to the epidural steroid injection, because this code represents a complete diagnostic imaging study. According to the August 2000 CPT Assistant , "Code 72275 should be reported only for a formally interpreted contrast study involving multiplanar imaging generating 'hard copy' images. Code 72275 includes fluoroscopic guidance and localization. Therefore, code 76005 should not be reported in addition to code 72275."
In general, the fluoroscopic guidance is assigned code 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).
If a contrast epidurogram is performed in conjunction with a therapeutic steroid or anesthetic agent injection by way of a lumbar puncture site, then coders should use RS&I code 72275 in conjunction with the injection procedure. You would assign the steroid injection code 62310 (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; cervical or thoracic) or 62311 (& lumbar, sacral [caudal]), depending on the area of the spine injected.
However, if only a steroid injection is performed without a full and complete epidurogram, you should use RS&I code 76005 together with the anatomically specific procedure code (e.g., lumbar, thoracic or cervical) and approach (e.g., transforaminal or unspecified). The transforaminal epidural codes are in the series 64479-64484 (Injection, anesthetic agent and/or steroid, transforaminal epidural). Codes 62310 and 62311 describe the epidural or subarachnoid codes without approach specified. You would assign the code for transforaminal injection only when the documentation supports a transforaminal approach.
