# Epidural and Transforaminal Epidural on the same day.



## HBROCKMAN (Aug 30, 2011)

This is stumping me a little.  My physician performed an epidural on a patient, but after injecting Marcaine and Depo Medrol he noticed a filling defect, possibly indicative of adhesions and/or stenosis.  So he then perfomed a transforaminal epidural where he again injected Marcaine and Depo Medrol.  I know that it is almost impossible to get the two of these paid together so I was wondering if a modifier on one of the procedures...like 51, 52 or 59 would help or if I should just not bill for the epidural at all and only bill for the transforaminal epidural?

Any information regarding this would be seriously appreciated.  Thank you in advance!


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## dwaldman (Aug 30, 2011)

59 would not be appropriate at the same spinal level. Although 59 modifier might override the edit using the logic that they are different spinal levels for some instances some might bill. As seen below from the AMA CPT Network, they are stating they are both non-neurolytic epidurals in the same spinal region, they don't recommend reporting both codes during the same encounter is what I take from this response. 

___________________________________________________________
Date: 06/22/2010 

Surgery 

Nervous System 

Question 

In which instances would it be appropriate to report codes 64483 and 62311 together? 

Answer 

Code 62311, Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal), describes epidural or subarachnoid injections of non-neurolytic substances including opioids, steroids, antispasmodic, and anesthetic substances, and does not differentiate between types of substances injected, but rather focuses on the route of administration (ie, single injection [not via indwelling catheter] versus continuous infusion or intermittent bolus via catheter). However, it is important to recognize that code 62311 excludes injection/infusion of a neurolytic substance, which is reported by codes 62280-62282. Therefore, based on the above information and in answer to your specific question, since code 62311 includes the injection of non-neurolytic substances, it would not be appropriate to separately report code 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.


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## dwaldman (Aug 31, 2011)

Below is from a Medtronics 2009 webinar presented by Joanne Mehmert: Pain Management Billing and Coding

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Transforaminal/interlaminar

Q I have a provider who did a right sided L4-L5 transforaminal epidural steroid injection and interlaminar epidural injection at L4,L5,S1 How would I code for this

A When two different surgical approaches are used to accomplish the same goal, it is not appropriate to report both procedures. In the situation described, the injections are made at the same spinal level, a contiguous anatomical region; it would not be appropriate to report both procedures. A transforaminal epidural 64479/64483 is mutually exclusive to a translaminar epidural 62310/623111.

The CCI shows that a transforaminal epidural 64479/64483 is mutally exclusive to a translaminar epidural 62310/62311. Although a bypass modifier (59) is allowed, the modifier is not appropriate when the injection is at the same spinal level to treat the same condition. 

If the provider attempts to perform the injection using the interlaminar technique and finds that the dye does not spread, then changes his/ approach to the transforaminal, only the transforaminal injection should be reported. AMA literature show examples of this coding principle for endoscopic procedures converted to open procedures---report only the "open" code.


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## HBROCKMAN (Aug 31, 2011)

Thank you so much for your answer!  I feel completely comfortable coding this now and that is usually something I struggle with.   Have a wonderful day!


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