Please refer to the CPT Assistant below. It explains why codes 64480 & 64484
were developed and should dispel the notion that modifier 59 has to be utilized when coding these procedures. As stated previously, I have coded 64484 (for multiple levels, as separate line items) to Medicare with only "anatomical" modifiers and have never been notified by our billing office as to denials for duplicate procedures.
Transforaminal Injection(s): Single vs Multiple Levels
To differentiate technique and code usage, the transforaminal epidural injection codes 64479-64484 describe both diagnostic and therapeutic nerve root injections that enter the epidural space through the intervetebral foramen requiring separate needle insertions at several unilateral spinal levels. This technique differs from interlaminar epidural injection technique (62310-62311) and the facet joint nerve injection technique (64470-64476). Fluoroscopic guidance and contrast material is used to localize the flow pattern (eg, either in the foramen and into the epidural space, or in a facial plane, or in an epidural vein). The needle is moved until contrast outlines the selected spinal nerve and flows into the foramen and then into the epidural space. 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.
Depending on the treatment required, multiple spinal levels may require injection (eg, foraminal stenosis from a variety of disorders, cervical spondylosis, lumbar spinal stenosis, postoperative back and leg pain, herniated discs in the far lateral or neuroforaminal position). Previous cervical or lumbar fusions make this procedure more difficult. In the case of a previous lumbar or cervical fusion, sometimes the only way to access the injured nerve root is through the transforaminal approach.
Since there can be multiple levels of pathology, which may require more than one injection site for diagnostic and therapeutic reasons, codes 64480 and 64484 were established. When performing transforaminal epidural injections at different levels, the patientâ€™s position does not change, but a new injection at the different level is performed. Each level is a separate injection with more physician work needed. Multiplanar real-time fluoroscopic imaging is mandatory for any transforaminal injection. When a transforaminal injection is performed on the opposite side, the work may involve redraping and positioning of the patient. Therefore, when performing bilateral transforaminal epidural injections at a single spinal level, modifier 50 is appended to the appropriate code(s).
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Karen Maloney, CPC
Data Quality Specialist