Question: A patient complains of severe low back radiculitis. The provider injected a combination of anesthetic and steroid (triamcinolone and methylprednisolone), using a 3-1/2-inch spinal needle, in the left L3-L4 neuroforaminal epidural space, under fluoroscopic guidance. How do we report this?
Utah Subscriber
Answer: You may report this with 64483 (injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT; lumbar or sacral, single level], along with modifier LT [left side]). This procedure is the injection of an anesthetic agent or steroid as a transforaminal epidural into a single level (either lumbar or sacral).
Note: For transforaminal epidural injection under ultrasound guidance, you may use0230T (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level).
Remember that CPT® codes 64479-64484 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]…) are unilateral procedures. For bilateral procedures, use modifier 50 (Bilateral procedure).
