64483: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
64484: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
Notes:
(Use 64484 in conjunction with 64483)
(For transforaminal epidural injection under ultrasound guidance, use 0231T)
(64479-64484 are unilateral procedures. For bilateral procedures, use modifier 50)
I would request clarification on whether the first injection was at L4-L5 or L5-S1 or if he did both levels, and whether there were bilateral injections. From an auditor's viewpoint, this is poor documentation that only supports a 64483.