Pain Management Coding Alert

Question: When I use code 62311, how do I capture the “bilateral” portion? The descriptor states “single” injection, but I have a note of “bilateral epidural space” in the physician dictation. I know that this code does not allow for modifier 50 (Bilateral procedure), and when I tried billing it with two units, I received a denial. Should I use 64483 instead since it allows for modifier 50?

Arizona Subscriber

Answer: CPT® does not consider interlaminar epidural injections to be unilateral procedures. The injection includes a moderate amount of medication that spreads throughout the whole epidural space, meaning both sides. However, that statement doesn’t always hold true.

A few patients anatomically have an epidural septum that prevents the spread of contrast and, likewise, the medication. Also, the patient could have a large herniation that impinges on the anterior epidural space. Then the physician may be forced to perform a second procedure in an attempt to get the anesthetic/steroid to the contralateral side. Many times the second injection is transforaminal and not interlaminar, so you should look at two codes:

• 62311, 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; lumbar or sacral (caudal)
• 64483, Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level.

You must have good documentation of the problems the physician encountered during the spread of contrast for these scenarios. If you do, you can add modifier 59 (Distinct procedural service) to the injection code because the physician performed two procedures with supporting medical necessity. This modifier overrides the Correct Coding Initiative (CCI) edit (in conjunction with clear documentation).

However, you may encounter difficulty when the physician provides two interlaminar injections at the same level and setting. For this rare instance, your supporting documentation must hit the “awesome” category, because most payers will not process second interlaminar injection. You can always appeal the denial with a letter requesting review by a physician of a similar specialty and a strong letter of medical necessity by your physician.