Neurology & Pain Management Coding Alert
T12-L1 Represents a Single Level Injection
Question: The procedure performed was “Right T12-L1 transforaminal epidural steroid injection.” Would I code this as 64479 and 64480, or as 64483 and 64484? Or would I code 64479 for thoracic and 64483 for lumbar? Would this be considered one or two levels?
Illinois Subscriber
Answer: The appropriate code for this scenario is 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level).
Explanation: Although two areas of the spine were referenced, you’re coding for a single spinal level injection. T12-L1 is one level with only the singular T12 spinal nerve exiting the vertebral foraminal opening. CPT® also includes the following parenthetical note: “For transforaminal epidural injection at the T12-L1 level, use 64479.”
Neurology & Pain Management Coding Alert
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