CPT Code 62321: Cervical or Thoracic Epidural Steroid Injection

What is a cervical or thoracic epidural steroid injection (CPT 62321)?

A cervical or thoracic epidural steroid injection is a procedure where medication is delivered into the space around the spinal cord to help reduce inflammation and pain. It’s usually done when a patient has neck, upper back, or radiating arm pain caused by conditions like herniated discs, spinal stenosis, or nerve root irritation. These injections can offer relief when other treatments like rest, physical therapy, or medication haven’t worked well enough.

CPT code 62321 refers to this specific type of injection. It falls under the Current Procedural Terminology system, a standardized coding framework maintained by the American Medical Association (AMA) to ensure accurate billing and precise documentation of medical, diagnostic, and surgical procedures.

CPT code 62321's full description is: Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT). That’s a long one, but it basically means a needle or catheter is used to inject medicine into the epidural space in the cervical or thoracic spine.

The “interlaminar” approach means the needle is placed between two vertebrae to reach the epidural space. Imaging guidance, like fluoroscopy or a CT scan, ensures the needle goes exactly where it should, helping keep the procedure safer and more effective. The injected substances can include steroids to reduce inflammation or anesthetics to numb the area. While it’s not a permanent fix, it can bring meaningful relief and buy time for other treatments to work.

CPT code 62321 documentation requirements

Proper and accurate documentation is essential when it comes to billing and reimbursement. Requirements that should be in a patient's medical record include:

• The provider’s assessment that directly relates to the patient’s reason for the visit
• Indications and medical necessity
• Important details from the patient’s medical history
• Results from any relevant tests or procedures
• Films that adequately document (minimum of 2 views) the final needle position and contrast flow
• A signed and dated record of the office visit or procedure note (Medicare requires signatures on all services provided)
• Documentation must justify ICD-10-CM codes and accurately reflect CPT/HCPCS services provided.

CPT code 62321 billing guidelines

In terms of billing essentials, here is what's worth considering or remembering:

• Avoid using epidural CPT codes (like 62321) for chemotherapy or complex drug administration. Instead, refer to CPT codes 96401–96549, which cover chemotherapy and other highly complex drug or biologic agent administration.
• Performing caudal or interlaminar epidural steroid injections (ESIs) on both sides isn’t considered medically necessary, so CPT codes 62321 and 62323 are not billed as bilateral procedures.
• According to the Local Coverage Determination (LCD) guidelines, CPT code 62321 should only be used for one level during a single session.
• A maximum of four ESI sessions using CPT 62321 can be reported for each spinal region within any 12-month period, regardless of the number of levels treated.

Other related CPT codes

Epidural CPT codes are essential in pain management because they help accurately document and bill for procedures that deliver medication directly to the spine to relieve inflammation and nerve pain.

In addition to CPT 62321, here are other important codes:

• 64479: Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level
• 64480: Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
• 64483: Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
• 64484: Injection(s), anesthetic agent(s) 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)