Transforaminal epidural injection coding

Transforaminal epidural injection CPT codes (64479-64485) include fluoroscopic or CT guidance so CPT code 77003 should be reported along with 64479-64485 codes. These codes represent unilateral service and hence modifier 50 is required to report bilateral service. Modifiers LT and RT are also required if only unilateral service is provided. The anesthetic and steroid injection material is included in the codes.

ICD procedure coding requires three codes:

03.91

Injection of anesthetic agent into spinal canal for analgesia

03.92  Injection of other agent into spinal canal

99.23 Injection of steroid or cortisone



If the injection includes both steroids and anesthetics assign code 03.92, 03.91, and code 99.23

EXAMPLE :

 PREOPERATIVE DIAGNOSIS:

1. Right lower extremity lumbar radiculitis.

2. Lumbar recess foraminal stenosis L4-5 and L5-Sl.

3. Lumbar recess stenosis L3-4.



POSTOPERATIVE DIAGNOSIS:

  Same as above.



OPERATION PERFORMED:

Right L4-5 and right L5-Sl transforaminal epidural under fluoroscopy.



COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room.The

skin area from T 12 to the sacrum was prepped and draped in a sterile manner with

chlorhexidine. The patient was sedated during the procedure.

Fluoroscopy was turned on. The C-arm was placed in an oblique view to right side.

Then the skin and subcutaneous tissue superior to the right L4-5 and L5-S 1 foramen

was each infiltrated with 3 mL of 1% Xylocaine. Using intermittent fluoroscopy from

an oblique trajectory 22-gauge spinal needles were gently and gradually advanced

under the 6 o’clock position of the right IA and L5 pedicle towards the right L4-5

and L5-Sl foramen. The needle was further visualized and advanced in

anterior-posterior view directing each needle tip directly underneath the 6 o’clock

position of the right IA and L5 pedicles into the superior aspect of the right L4-5

and L5-S1 foramen. After a negative aspiration for cerebrospinal fluid, heme or air,

1 mL of Isovue contrast was injected into the right L4 and L5 dural nerve root

sleeves with excellent evidence of contrast flow into the epidural space.



Once again after a negative aspiration for cerebrospinal fluid, heme or air, 1 niL

of (6 mg) of Celestone and 2 mL of 1% preservative free Xylocaine, and 1 mL of 0.25%

bupivacaine was placed into each dural root sleeve into the epidural space.

The patient tolerated the procedure without complications.



DX       CODE   DESCRIPTION              

1          724.4   Thoracic/Lumbar Neuritis/Radiculitis NOS

2          724.02 Spinal Stenosis, Lumbar Region, WO Neurogenic Claud

PX    CODE   DESCRIPTION             

1          03.91   Injection Anesthetic Spinal Canal For Analgesia                       

2          03.92   Injection Agent NEC Into Spinal Canal            

3          99.23   Injection of Steroid                  

CPT     CODE   DESCRIPTION                                                    MODIFIER            

1          64483   Transforaminal epidural injection Lumbar/Sacral          RT             

                         single level

2          64484   Transforaminal epidural injection Lumbar/Sacral each  RT            

                          additional level