CPT code 62323: Epidural injection

What is CPT code 62323?

CPT code 62323 describes a primary procedure involving the injection of diagnostic or therapeutic agents, such as anesthetics, antispasmodics, opioids, or steroids for pain management, into the lumbar or sacral (caudal) region of the spine. This is commonly performed as part of injections for pain management, particularly in patients with conditions like stenosis of the neural canal or stenosis of the intervertebral foramina that causes nerve root compression and radicular pain.

This epidural injection CPT code includes the placement of a needle or catheter under fluoroscopic or CT guidance, often using contrast to confirm proper medication delivery. This imaging may involve advanced techniques such as fluid flow imaging, cisternography, or cerebrospinal fluid flow imaging to ensure accurate needle placement and assess flow dynamics when clinically indicated.

Importantly, CPT code 62323 does not apply to procedures involving neurolytic substances intended to intentionally destroy nerve tissue.

CPT code 62323 documentation requirements

For accurate billing and coding of epidural steroid injections, including claims submitted to Medicaid services, it is essential to document medical necessity, imaging guidance, and the therapeutic agents administered. Below are the key documentation requirements:

Medical necessity and diagnosis

The documentation must clearly support the medical necessity of the injection. This includes a confirmed diagnosis such as lumbar or sacral radiculopathy, neurogenic claudication, disc herniation, or post-laminectomy syndrome. The clinical notes should describe the patient’s symptoms, their severity, and how they impact function or quality of life.

Conservative treatment history

The record must show that the patient has failed to respond to a reasonable trial (typically at least four weeks) of conservative, non-invasive treatments such as physical therapy, oral medications, or activity modification. If the injection is for acute herpes zoster, documentation should show that the condition is refractory to initial conservative management.

• Radiological evidence: Diagnostic imaging (e.g., MRI or CT) that correlates with the patient’s clinical presentation must be included. The findings should support the presence of structural abnormalities such as spinal stenosis or nerve root impingement at the level targeted for injection.
• Procedure details: The note must describe the site (lumbar or sacral), the type of approach (interlaminar epidural or subarachnoid), and the laterality if applicable. It should also detail the use of fluoroscopic or CT guidance, confirm needle placement using contrast, and discuss the substances injected, including dosages and volume.
• Use of imaging guidance: The documentation must explicitly state that imaging guidance was used (fluoroscopy or CT), and that contrast was administered to confirm proper epidural spread—unless contraindicated due to allergy or pregnancy. If contrast is not used, a justification must be provided.
• Medications administered: All medications injected should be listed by name, including the type (e.g., anesthetic, corticosteroid), dose, and total volume. If a mixture is used, each component must be detailed.
• Informed consent: The medical record must include documentation that the patient was informed of the risks, benefits, and alternatives, and that verbal or written consent was obtained before proceeding with the injection.
• Post-procedure assessment: The documentation should include the patient’s status after the procedure, noting any immediate effects or complications. If this is a follow-up injection, it should also include the patient’s response to prior injections.
• Functional or pain assessment: Objective measures such as a pain scale (e.g., 0–10) or functional assessment tool (e.g., Oswestry Disability Index) should be recorded at baseline and repeated at follow-up visits to assess the response to the intervention.

CPT code 62323 billing guidelines

Understanding the proper billing and coding for epidural steroid injections is essential to ensure reimbursement compliance and prevent denials.

• CPT 62323 should be billed for a single spinal level per session. Reporting multiple levels under this code is not permitted.
• No more than four epidural steroid injection sessions (including CPT codes 62321, 62323, 64479–64484) are reimbursable per anatomic region within a 12-month rolling period, regardless of the number of injection levels per session.
• The use of fluoroscopy or CT imaging is mandatory to confirm accurate needle placement and contrast flow. In cases where contrast use is contraindicated, such as documented allergies or pregnancy, alternative imaging methods may be considered. ​
• CPT 62323 does not apply to bilateral procedures. Epidural injections for pain via the caudal or interlaminar approach are typically unilateral and should be billed as such.
• For diagnostic selective nerve root blocks coded identically to epidural injections, the -KX modifier should be appended to distinguish the procedure. Incorrect use of modifiers may lead to claim denials or audits.

Other relevant codes

• CPT code 62322: Injection, drainage, or aspiration procedures on the spine and spinal cord
• CPT code 64479: Single-level injection performed with image guidance
• CPT code 64480: Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the somatic nerves
• CPT code 64484:  Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the somatic nerves