Coding transforaminal epidural steroid injection

“The primary codes 64479, 64483, 64490 and 64493 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480, 64491, 64492 (cervical/thoracic) and 64484, 64494 and 64495 (lumbar/sacral) for use when injections are provided at multiple spinal levels. Unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level. The Centers for Medicare and Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50.”

... wall subcutaneous fluid collection. Using CT guidance an appropriate skin entrance site was obtained and marked and prepped and dressed in normal sterile fashion." Local anesthesia then "....19-gauge needle cyst was accessed. Approx 30 ml of serous straw-colored fluid was obtained. With needle still in place within the cyst, a mixture of doxycycline, marcaine and solu-medrol was injected into the cyst cavity for sclerotherapy." Radiologists want to code 49021 & 75989. No mention of catheters. My thoughts are 77012 and 10160. Maybe 49999 for the sclerotherapy of the cyst. My background is cardiovascular and not non-vascular IR, so I am not very familiar with this aspect. I might also mention that samples of the fluid were sent to the lab for testing. Thank you very much!!

CPT Code Changes
Separate from the annual changes in Medicare payments, the CPT Code Book also is updated annually. This year, though, there were few changes for reporting CPT codes for diagnostic radiology procedures. An overview of key changes to diagnostic radiology codes are discussed below. (Note: The majority of the CPT code changes for 2013 are related to interventional radiology. These services will be mentioned but will not be discussed in detail here, as they warrant their own article. This topic will be discussed in more detail in Radiology Today ’s February issue.)

8. CPT codes 64400-64530 describe injection of anesthetic agent for diagnostic or therapeutic purposes, the codes being distinguished from one another by the named nerve and whether a single or continuous infusion by catheter is utilized. All injections into the nerve including branches described (named) by the code descriptor at a single patient encounter constitute a single unit of service(UOS). For example:
(1) If a physician injects an anesthetic agent into multiple areas around the sciatic nerve at a single patient encounter, only one UOS of CPT code 64445 (injection, anesthetic agent; sciatic nerve, single) may be reported.
(2) If a physician injects the superior medial and lateral branches and inferior medial branches of the left genicular nerve, only one UOS of CPT code 64450 (Injection, anesthetic agent; other peripheral nerve or branch) may be reported regardless of the number of injections needed to block this nerve and its branches.

Coding transforaminal epidural steroid injection

coding transforaminal epidural steroid injection

8. CPT codes 64400-64530 describe injection of anesthetic agent for diagnostic or therapeutic purposes, the codes being distinguished from one another by the named nerve and whether a single or continuous infusion by catheter is utilized. All injections into the nerve including branches described (named) by the code descriptor at a single patient encounter constitute a single unit of service(UOS). For example:
(1) If a physician injects an anesthetic agent into multiple areas around the sciatic nerve at a single patient encounter, only one UOS of CPT code 64445 (injection, anesthetic agent; sciatic nerve, single) may be reported.
(2) If a physician injects the superior medial and lateral branches and inferior medial branches of the left genicular nerve, only one UOS of CPT code 64450 (Injection, anesthetic agent; other peripheral nerve or branch) may be reported regardless of the number of injections needed to block this nerve and its branches.

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