# transforminal epidural injection



## colucci1967 (May 4, 2011)

Has anyone come across where the doctor states they do a transforminal epidural injection with fluroscope?  Medicare doesn't pay when the fluroscope is not done.  Is there another code that can be billed instead of the 64483 since the fluroscope was not done.

If anyone can help I would greatly appreciate the guidance.


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## danastiff (May 4, 2011)

*re:transforaminal injection*

Re: Has anyone come across where the doctor states they do a transforminal epidural injection with fluroscope? Medicare doesn't pay when the fluroscope is not done. Is there another code that can be billed instead of the 64483 since the fluroscope was not done.

If anyone can help I would greatly appreciate the guidance. *****

I'm a little confused as to whether or not the fluoro was used. In your first sentence it sounds like it was. What area of the body was the injection given in?


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## colucci1967 (May 4, 2011)

According to the note he did an Left L5 transforaminal epidural steroid injection, however the note does not support the use of fluroscope but he also states Omnipaque demonstrated good L5 nerve root but no retrograde filling.

Help


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## danastiff (May 4, 2011)

That sounds like fluor guidance to me. I would feel comfortable using the 64483. If you're not, ask the Dr. for clarification. Hope this helped.


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## brockorama01 (Jun 27, 2011)

Don't forget 77003 is bundled with 64483 and not billable.


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## dwaldman (Jun 27, 2011)

Below is an example of Local coverage determination policy from WPS Medicare J5. If there is question whether the procedure utilized fluoroscopic image guidance. I would query the physician. If you are billing Medicare for this type of procedure you would want to look at the LCD for the Medicare carrier you are billing and review requirements and billing and coding guidelines. As seen below they state fluroscopic guidance must be utilized. Assisting the physician in educating him/her of  the requirements of LCD or Medical policy of the carrier is very important and the policy can be updated so checking per month is necessary to make sure new requirements have not changed. Sometimes if you have questions about a procedure you are about to bill and you are going to post a question if you have the procedure note avaiable, you can copy and paste it. State here is the procedure note these are the codes I am thinking, Just confirming this is correct before releasing it. This way there is something  suggest a point of view from the procedure note itself.

Below is the LCD stating fluoro is required

Therapeutic transforaminal epidural injections are appropriate for the following purposes:

Corticosteroid can be added as a therapeutic measure. Injections for therapeutic reasons can be of greater volume. The transforaminal injection can be performed for diagnostic, therapeutic or both purposes.

Radicular pain resistant to more conservative measures or when surgery is contraindicated.
Post-decompressive radiculitis or post surgical scarring
Monoradicular pain, confirmed by diagnostic block in which a surgically correctible lesion cannot be identified 
Treatment of acute herpes zoster or post herpetic neuralgia

Fluoroscopic guidance must be utilized in the performance of single nerve root/transforaminal injections to ensure the precise placement of the needle and medications injected.


Here some info from CPT Assistant Feb 2011

The following codes were revised for 2011:

64479    Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

 +64480Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

 64483   Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

 +64484Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

The transforaminal epidural injection codes64479-64484describe injections that enter the epidural space through the intervetebral foramen. This technique differs from interlaminar [translaminar] epidural injection technique (62310-62311) and the paravertebral facet joint nerveinjection technique (64490-64495). 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.

Transforaminal epidural injectioncodes 64479, 64480, 64483, and 64484 now include the fluoroscopic and computed tomographic (CT) needle placement imaging services in the code descriptors. Imaging guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of codes 64479-64484.

Consequently, the parenthetical instructions following code 77012,Computed tomography guidance for needle placement (eg biopsy, aspiration, injection, localization device), radiological supervision and interpretation, have been revised. This code is no longer reported in conjunction with the transforaminal epidural injection codes 64479-64484 and the paravertebral facet injection codes 64490-64495, as the imaging guidance is already included in these procedures.

Below is from


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## dwaldman (Jun 27, 2011)

Below is an pretty good example of how a procedure note for left L5 transforminal with image guidance should look, where it is very evident that fluoro was used in the procedure.

Indication:

Patient with a history of low back pain with radicular pain refractory to multiple treatment modalities. These include simple and prescription analgesics, rest & local measures, and caudal epidural nerve blocks. It is hoped that a transforaminal injection will be of additional diagnostic and therapeutic benefit.

Level: L L5

I have discussed the risks and potential benefits of this procedure with the patient. All questions were answered to the patient's satisfaction and the patient desires to proceed. Informed consent was obtained.

Description of procedure:

The patient was taken to the fluoroscopy suite and placed in the prone position to reduce the lumbar lordosis. After initial fluoroscopic localization, a sterile prep was done by nursing staff. The L L5 neural foramen was localized via fluoroscopy. After infilitration of the skin and deeper tissues with 1% lidocaine, a 22 gauge needle was advanced under multiple fluoroscopic views into the neural foramen at L5 on the left. One cc of isovue M 200 was used to clearly identify the proximal nerve root. This was followed by injection of 2cc of 2% lidocaine plus 40 milligrams triamcinolone without difficulty or complication.


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## dwaldman (Jun 30, 2011)

A recent Q and A on the AMA CPT Network might better addressed image guidance versus no image guidance in conjunction with a transforminal epidural 
Surgery 

Nervous System 

Question 

For CPT 2011, either fluoroscopy or computed tomographic (CT) needle guidance is required to qualify for reporting the transforaminal epidural injection codes 64479-64484 or ultrasound needle guidance for reporting Category III codes 0228T-0231T. How would a transforaminal epidural injection be coded if the physician did not use any image -guidance? Are the trigger point injection codes 20552 and 20553 reportable? 

Answer 

A transforaminal epidural injection cannot be performed without image guidance, therefore, a specific code recommendation cannot be provided if the physician does not use image guidance yet states that the in-tended target was the epidural space via a foramen. In this circumstance, code 64999, Unlisted procedure, nerv-ous system, should be reported. However, if a trigger point injection was the intended procedure, the physician should document the presence of the intra-muscular trigger point(s) and then specify the work done to inject the trigger point(s). It is then that trigger point code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 mus-cle(s), or code 20553, Injection(s); single or multiple trigger point(s), 3 or more muscle(s), may be reportable.


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