Wiki Coding Additional Levels for Transforaminal

[talitha82]

We are having a debate in our office regarding transforaminal injections. If the doc performs an injection on the right side, and then does a 2nd injection on the left side on a different level, would you code it as:

64483-RT
64484-LT

OR

64483-RT
64483-LT

We cannot find any documentation supporting either way. Any insight would help.

 

[Nat]

I would definitely use 64483 and 64484. The code 64484 states each additional level.

 

[talitha82]

I would definitely use 64483 and 64484. The code 64484 states each additional level.

That is the consensus of half of our office, and the other half argues that since it is a unilateral procedure, the 64484 on the LT side would need to be a primary code as well? We really want to find some kind of documentation to support either way, if possible. We are starting to get take backs from Medicare (RAC audits) because we were coding it the way of 64483-RT and 64484-LT.

 

[moodymom]

WOW...that's a good one! I can see were both sides are correct. It will be interesting to see how this works out! I will do some research.

 

[gsteeves]

If physician performs an injection to the right and left side of the same level of the lumbar area you would use 64483-50 or 64483 RT 64483 LT. You would use 64484 if it were at a different level, ex L4 and L5. Hope this helps.

Gail Steeves