Neurosurgery Coding Alert

Question: The provider injected a steroid into the space around the spinal nerves of the thoracic region. She inserted a needle to facilitate the injection, but she did not use imaging guidance. Which CPT^® code should we report for this procedure?

Texas Subscriber

Answer: You should report 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) for this procedure.

On the other hand, if the physician had performed this same procedure, but she did use imaging guidance, then you would report 62321 (… with imaging guidance (ie, fluoroscopy or CT)) instead.

And, if you read in the medical documentation that the physician performed the injection in the patient’s lower back or tailbone area, then you should report 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).