Pain Management Coding Alert

Question: Our physician’s op note states that he administered four selective nerve root injections at L4-L5 and L5-S1. He inserted the needle into the foramen at two levels under direct visualization and injected Marcaine and Dexamethasone. Could you please tell me the correct CPT® codes and correct units for reporting this service?

Arizona Subscriber

Answer: Part of your coding depends on whether the physician administered the nerve blocks on both the right and left sides. We assume he did since you mention four injections. If so, you should report the encounter as follows: 

• 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level)-RT (Right side) with 64483-LT (Left side) for the L4-L5 injections  

• 64484 (…lumbar or sacral, each additional level [List separately in addition to code for primary procedure])-RT with 64484-LT for the L5-S1 injections. 

Medicare note: Remember Medicare requires you to append modifier 50 (Bilateral procedure) to the procedure code instead of RT or LT. Report a single line item and unit of service for bilateral procedures.