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Wiki 64483 and/or 64484

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louettayg

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18
Location
San Diego, CA
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Transforaminal injection is given at the L5 level and another injection given at L5-S1 level. this is what the dr has documented.
Can he bill for 64483 and 64484 even though L5-S1 is usually billed as 1 injection 64483?
 
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.
 
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