Pain Management Coding Alert

Question: I’m new to pain management coding, so am learning a lot about the different types of injections. Can you explain what epidural steroid injections (ESI) are, and how to code them?

Alaska Subscriber

Answer: Epidural steroid injections (ESI) are given in the epidural space and may be either “translaminar/interlaminar” or “transforaminal” injections. Common terms your provider might document in the patient’s chart could include:

• Epidural space or extradural space: The area located inside the spinal canal that is separated from the spinal cord and the surrounding CSF (cerebrospinal fluid).
• Dura mater (dura): Separates the epidural space and the arachnoid membrane.
• Arachnoid mater: The area adherent to the inside of the dura that is more fragile than the dura.
• Subarachnoid space: The area inside the arachnoid space that contains CSF and the spinal cord.

Many injections are administered in this region. Mention of a subarachnoid injection might lead you to code 62284 (Injection procedure for myelography and/or computed tomography, lumbar). An example of a disc injection code is 62290 (Injection procedure for discography, each level; lumbar).

References to the spinal column itself might also be made in the provider’s notes.

Transforaminal epidural steroid injections are administered specifically in the foraminal opening between two vertebrae in the cervical (i.e., C4-C5), thoracic (i.e., T4-T5) and lumbar (i.e., L4-L5) spinal regions and into the posterior foraminal openings in the sacral area (i.e., S2).

Note: The regular ESI procedures (represented by codes 62310-62319) sometimes are referred to as “translaminar” or “interlaminar” injections. Don’t confuse these procedures with transforaminal ESI procedures (codes 64479/64480 for cervical/thoracic injections and 64483/64484 for lumbar/sacral). The target for each of these codes is different, with the transforaminal injection specifically targeting a single nerve root and requiring image-guidance for localization and confirmation of injection.

CCI edits: The Correct Coding Initiative (CCI) lists many edits related to ESI procedures.

For example, the edits bundle code 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level) into 62310 as mutually exclusive, i.e., rarely to never performed together. The CCI table also bundles 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) as a column 2 code into the column 1 code 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]).

Therefore, for Medicare and other payers who observe the CCI edits, you cannot bill these codes together when the injections are performed to the same spinal area during the same patient encounter.