Neurology & Pain Management Coding Alert

Code choice will vary depending on spinal area.

Epidural steroid injections (ESIs) are commonly used to relieve pain and inflammation associated with spinal conditions. These injections are simple procedures that are usually done in pain management (PM) offices. One size does not fit all when coding these shots, however. You’ll need to know the injection type, among other details, in order to code your claim correctly.

Read on for coverage of the specific guidelines for ESIs.

Maintain Documentation on Steroid Injections

Compliance with guidelines for Medicare local coverage determinations (LCDs) for ESIs vary by Medicare Administrative Contractor (MAC), but generally, there are conditions under which Medicare will cover the procedure. Clinical notes must support the medical necessity of the injection. Your physician’s documentation should detail failed conservative treatments such as physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), or other non-invasive therapies that the patient has undergone.

Providers must ensure the documentation is maintained and readily available to payers upon request. Documentation must be legible, with appropriate patient identifiers along with the signature of the provider caring for the patient.

The procedure is usually covered for chronic pain management in conditions such as lumbar or cervical radiculopathy, spinal stenosis, and disc herniation. A maximum of four injections per patient per year is allowed, unless the provider can justify additional injections per year to the payer.

Injections should also be spaced appropriately throughout the year, and continued treatment requires documented progress of pain levels and function. To justify continued injections, improvement must be documented.

Imaging Could Precede the Injection

Imaging studies may be required to confirm the diagnosis, which you should be able to report separately from the ESI. There are several types of imaging that your PM provider could use before an ESI: magnetic resonance imaging (MRI), computed tomography (CT), X-rays, etc. Be sure to code for the correct imaging procedure, when performed.

ESIs can be administered at different levels of the spine, dependent on the location of the pain and the affected nerve roots. The levels are split up into regions for injection. First you have cervical ESIs, which will be administered in the neck region. Cervical ESIs usually address cervical radiculopathy, which is often caused by herniated discs or spinal stenosis.

In the next level you have thoracic ESIs, which will be given in the mid-back region, typically for thoracic nerve compression. Then, you have lumbar ESIs, which are administered in the lower back to relieve pain from lumbar radiculopathy, spinal stenosis, or disc herniation.

The final level is caudal ESI, which is administered at the sacral hiatus and often used for widespread lower back and leg pain (usually when multiple nerve roots are affected). Each level targets specific nerve roots based on the patient’s symptoms and diagnosis. The choice of injection site depends greatly on the location of nerve inflammation and compression.

Use These ESI Codes

ESIs have specific CPT^® codes that vary based on the injection site and whether imaging guidance is used. These codes are categorized into base codes and add-on codes. For interlaminar ESIs, report only one base code per session. For transforaminal ESIs, bill one base code per treated level per side, plus add-on codes for each additional level on the same side.

Here's a look at the ESI codes you’ll be using for your PM provider’s services:

Single-injection CPT^® codes

• 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance)
• 62321 (… with imaging guidance (ie, fluoroscopy or CT))
• 62322 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance)
• 62323 (… with imaging guidance (ie, fluoroscopy or CT))

Transforaminal approach codes

• 64479 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level)
• +64480 (… transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure))
• 64483 (… transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level)
• +64484 (… transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure))

Make note: Imaging guidance (fluoroscopy or CT) is typically required and included in 62321 and 62323. Do not bill separately for fluoroscopy when using these codes. If performing ESIs at multiple levels, the appropriate add-on code for each extra level must be listed.

For billing purposes, best practice is to assign the number of levels in the unit block of the CMS-1500 claim form. It is important to use the appropriate base CPT^® code for the first injection and add-on codes for each additional level. CPT^® codes 62321, 62323, 64479, +64480, and +64484 can only be billed for four sessions per anatomical region in a rolling 12month period regardless of the number of levels involved.  

Don’t Forget the Modifiers

Some payers require modifier 50 (Bilateral procedure) for bilateral injections, while others prefer RT (Right side) and LT (Left side). Further, you’ll need modifier KX (Requirements specified in the medical policy have been met) for Medicare claims when the ESI exceeds frequency limits.

Remember: ESI codes include the cost of the medication, supplies, and guidance. Separate billing for these components is not allowed.

Crystal Nguyen, CPC, Certified Coding Specialist, Risk Adjustment/Hospital/Coding Audit and Education,
Pinnacle Enterprise Consulting Services (PERCS)