Neurology & Pain Management Coding Alert

Question: The physician administered transforaminal epidural steroid injections to the right L3, L4, and L5. How should we code this encounter for Medicare?

Georgia Subscriber

Answer: First, begin with the correct injection codes 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) and 64484 (...lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).

Next, look at how to report the codes. Remember that with Medicare, you report the number of units for each code on a single line rather than listing each code individually. List the spinal level in HCFA box 19 on the claim. Your coding would be as follows:

• 64483 -- L3
• 64484 -- 2 units -- L4, L5.

You'll also want to include the anatomic modifier LT (Left side) or RT (Right side), whichever is appropriate.