Wiki Transforaminal epidural steroid injection

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jminick78

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Can anyone help me out. I am confused as to when you use the 64484 add on code for an additional level for TFESI. I have a physician that states in his dictation that he injects into the L5 neuroforamen and the S1 neuroforamen. Would this be considered two levels? After looking all over the internet I can not seem to find a clear example as to what an actual level would be for this code.

Would you bill 64483 for the L5 and 64484 for S1? Are these two linked and then it is one level? What also throws me off is under the 64480 in the CPT book it states that (for transforaminal epidural injections at the T12-L1 level use 64479. I feel like this would be one level the L5/S1 but the physician is telling me that this is two levels because he is targeting two nerve roots.

If anyone has any sites or can help me with coding these procedures I would greatly appreciate it or a site that clearly defines what a "level" is. I was under the impression that for two levels it would have to state L4-L5, L5-S1.

Thanks
 
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L5-S1 is the same level - the foramen and the epidural space are between any two vertebral segments, so it requires two vertebrae to identify each single level - the L5 cannot be considered a separate level from the S1 in this particular coding scenario. Since the code description for transforaminal injections is 'per level', not 'per injection' or 'per nerve root treated', you can only code one unit even if the physician has documented treating more than one site within that level - the exception of course being that it can be billed bilaterally if both the left and right sides are injected.

As a reference, you can cite CPT Assistant, November 1999, which states specifically that these codes are "reported once regardless of the number of injections performed at a particular spinal level."
 
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So in order for it to be two levels the physician would have to dictate L4-L5 neuroforamen and the L5-S1 neuroforamen? I am still a little confused because is the S1 neuroforamen a different level/segment than the L5 neuroforamen? Like is the L5 neuroforamen between the L4-L5 vertebra and the S1 neuroforamen between the L5-S1 neuroforamen. I just want to be sure because I was told that I was completely wrong by the physician.
 
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Well, maybe your confusion is if a procedure is done on a particular vertebra, that one vertebra = one level. When the work is done between two vertebra, that still equals one level. Look at a picture of a spine and identify the anatomic references made in the op note to get a clear picture in you mind of what is going on.
 
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jminick78 said:
So in order for it to be two levels the physician would have to dictate L4-L5 neuroforamen and the L5-S1 neuroforamen? I am still a little confused because is the S1 neuroforamen a different level/segment than the L5 neuroforamen? Like is the L5 neuroforamen between the L4-L5 vertebra and the S1 neuroforamen between the L5-S1 neuroforamen. I just want to be sure because I was told that I was completely wrong by the physician.
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I think I see where the confusion is, as it seems that the physician may be naming the spinal nerve that he is treating rather than the neuroforamen. As the post above points out, the nerve roots exit between the vertebral segments, so for each vertebra, there is a nerve above it and a nerve below it. Most physicians I've coded for always document the location the vertebrae above and below, e.g. L4-L5, and if the physician is just naming one and using this notation to refer to one or the other of the neuroforamina, it is not clear to me which nerve he is treating and I believe it wouldn't be clear to a payer auditor either.

Below S1, however, the vertebra are fused, so there really isn't an S1-S2 'joint' - the opening in the sacrum where the S1 nerve exits may be just referred to as the S1 sacral foramen. I suspect this may be what your physician is doing here - an injection at L5-S1 to treat the L5 nerve root, and an injection at the S1 foramen (S1-S2) for the S1 nerve. If that is the case, then the additional level would be supported and some minor clarification in documentation would make this clear for the coders and auditors.
 
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Thank you I agree that his wording was terribly confusing. I researched what seemed like the whole internet trying to find out how he could think what he said was two levels and then I found a photo diagram where it showed an L5-S1 injection and then another different injection into the S1 which is what my physician was doing but just not stating it like I thought it should look like for two levels. I hope he will take my advice about how he is documenting this in the future but if not now I at least understand what he is trying to say!
Thanks a bunch!
 
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jminick78 said:
Thank you I agree that his wording was terribly confusing. I researched what seemed like the whole internet trying to find out how he could think what he said was two levels and then I found a photo diagram where it showed an L5-S1 injection and then another different injection into the S1 which is what my physician was doing but just not stating it like I thought it should look like for two levels. I hope he will take my advice about how he is documenting this in the future but if not now I at least understand what he is trying to say!
Thanks a bunch!
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Welcome to coding "In the real World'. This is the type of situation I try and train new coders for. There is one type of "coding' to pass the CPC exam and then there is this, what goes on in the real world where insurance companies see things differently, physicians see things differently and document differently as well.
 
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Orthocoderpgu said:
Welcome to coding "In the real World'. This is the type of situation I try and train new coders for. There is one type of "coding' to pass the CPC exam and then there is this, what goes on in the real world where insurance companies see things differently, physicians see things differently and document differently as well.
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I agree with "coding to pass" vs "real world"! And for some reason doctors act like more codes/procedure = better pay, regardless of what the code description indicates. So in real world, the coder has to know the insurance nuances as well as the biller?
 
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When I first started in pain management, my boss was doing epidurals. I looked at the codes, and I saw the words "transforaminal" and "interlaminar". His op reports always said either "translaminar" or "interforaminal". I told him, "Dude, pick a word that exists!!!"
 
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