Orthopedic Coding Alert

Question: I have some questions about coding for epidural steroid injections (ESIs). Patient #1 that I’m coding for had ESI of the L4/L5 joint. Patient #2 had bilateral ESI of the L3/L4. How should I report these? Do I need multiple codes (such as +64484) for the bilateral procedure?

Florida Subscriber

Answer: For Patient #1, report code 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level). You should also report 64483 for Patient #2, but append modifier 50 (Bilateral procedure) because the provider administered bilateral injections.

Note that code 64483 represents a single level injection. Code +64484 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)) is an add-on code, but represents additional injections to another level, not additional injections to the same anatomic site.

Example: If a patient comes in with a complaint of lower back pain and the provider decides to perform ESI at two different levels (L3-L4 and L4-L5), it would be appropriate to report both 64483 and +64484.