Neurosurgery Coding Alert

Question: The surgeon gave the patient a single-level cervical transforaminal epidural to treat his radiculopathy. What code should we report for this service?

Alaska Subscriber

Answer: You should report 64479 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level) when the physician administers a single-level injection in the patient’s cervical or thoracic area.

Don’t miss: You also have add-on code +64480 (Injection(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)) that you can report with 64479 if your surgeon injects a transforaminal epidural into levels additional to the primary procedure (either cervical or thoracic).