Radiology Coding Alert

Question: Which CPT codes should I report if the radiologist performs a fluoroscopically guided, single-level thoracic transforaminal epidural injection?

Minnesota Subscriber

Answer: You should report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) for the fluoroscopic guidance.

You may separately report the epidural injection with 64479 (Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level).

Radiologists perform thoracic epidural injections to relieve pain in the upper back, down the ribs, and in the abdomen, which impinged thoracic spine nerves may be causing. The steroid can reduce nerve inflammation caused by spinal conditions, such as herniated discs (example: 722.x, Intervertebral disc disorders) and spinal stenosis (example: 724.01, Spinal stenosis; thoracic region).

The fluoroscope helps the radiologist locate the thoracic vertebra and nerve root and direct the needle into the foraminal space.