Neurosurgery Coding Alert

Question: The physician documented transforaminal epidural steroid injections (TFESI) at levels L4 and L5. Is this correct, or should he have documented levels L4-L5 and L5-S1? Also, can we code with both 64483 and 64484?

Michigan Subscriber

Answer: Yes, you can report both 64483 (Injection(s), anesthetic agent(s) 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)) if you have clear documentation of the physician administering injections at both levels.

Code 64483 represents a single-level injection; you can report one unit of 64483 per day. Code +64484 is an add-on code, but represents additional injections to another level, not additional injections to the same anatomic site. You can report four units of +64484 for different levels.

Nerve roots are anatomically situated at the intervertebral segments. In the lumbar spine, the exiting nerve root that is targeted is anatomically named after the rostral or more cranial vertebral body under whose pedicle the nerve passes. For example, L4-L5 is associated with nerve root L4 and L5-S1 is associated with nerve root L5. TFESI should be reported once for each level targeted, regardless of the number of injections or injection attempts at that level.

That means when a patient comes to the pain management specialist with a complaint of lower back pain and the provider decides to perform TFESI at two different levels (L3-L4 and L4-L5), it would be appropriate to report both 64483 and +64484 for targeting the L3 and L4 nerve roots. Remember to also append modifier 50 (Bilateral procedure) if the provider administered bilateral injections. Append modifier RT (Right side) or LT (Left side) as appropriate if injections are administered unilaterally.