Radiology Coding Alert

Question: The physician administered transforaminal epidural steroid injections to the right L3, L4, and L5 under fluoro. How should we code this encounter for Medicare?

Georgia Subscriber

Answer: First, begin with the correct injection codes: 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) and +64484 (...lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).

Next, look at how to report the codes. Remember that with Medicare, you report the number of units for each code on a single line rather than listing the same code (if applicable) multiple times. List the spinal level in box 19 (or the electronic equivalent) on the claim. Your coding would be as follows:

• 64483 for L3
• +64484, 2 units, for L4, L5.

You'll also want to include the anatomic modifier LT (Left side) or RT (Right side), whichever is appropriate. In this case, you indicate right side injections, so you should append modifier RT on each line item.

Bonus tip: For information on common issues related to supporting epidural steroid injection claims, review the MLN Matters article at www.cms.gov/MLNMattersArticles/Downloads/SE1102.pdf.