Radiology Coding Alert

Question: Our radiologist performed an epidural L5 nerve block and gave facet steroid injection bilaterally at the L3-L4 and L4-L5 levels. How do we report these services?

North Carolina Subscriber

Answer: For the epidural nerve block, you report code 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level). For the facet joint steroid injection at L3-L4, you report code 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) and append modifier 50 (Bilateral procedure). For the L4-L5 level, you report code 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) -50.

You may report 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]) as there seem to be no bundling issues with 64493. However, it is good to review the local coverage determination policy for your Medicare carrier.

Why multiple nerve blocks? Multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. It is reasonable to use the modality most likely to establish the diagnosis or treat the presumptive diagnosis. If the first procedure fails to produce the desired effect or rules out the diagnosis, the provider may proceed to the next logical test or treatment if desired.

Note: Providing a combination of epidural block, facet joint blocks, bilateral sacroiliac joint injections, lumbar sympathetic blocks or providing more than three levels of facet joint blocks to a patient on the same day is considered not reasonable or necessary. Since such combinations do not make good treatment, you may face difficulties in payment for multiple procedures.