Outpatient Facility Coding Alert

Question: Our pain management physician wants to bill for an aborted interlaminar epidural steroid injection (ESI) that was converted to a transforaminal ESI due to difficult anatomy. Can he bill for both the aborted injection and the completed transforaminal ESI?

Washington Subscriber

Answer: When the physician uses two different approaches to accomplish the same goal, it is not appropriate to report both procedures. This is especially true for situations like you face because the physician made injections at the same spinal level, a contiguous anatomical region. 

The codes most likely considered in this scenario are:

• 62310 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic) or 62311 (… lumbar or sacral [caudal]) for the translaminar epidural
• 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level) or 64483 (…  lumbar or sacral, single level) for the transforaminal epidural

You should report only the transforaminal epidural injection (64479) because it was the completed procedure. In addition, Correct Coding Initiative (CCI) edits show that a transforaminal epidural is a Column 2 code for a translaminar epidural and that the procedures are mutually exclusive. Although CCI allows you to append a modifier such as 59 (Distinct procedural service) to break the bundling edit, the modifier is not appropriate when the provider injects the same spinal level to treat the same condition.

Bottom line: Only report the transforaminal epidural. Select either 64479 or 64483 based on the injection location.