CPT Code 64483: Injection(s), Anesthetic Agent and/or Steroid, Transforaminal Epidural, Lumbar or Sacral, Single Level

What is a transforaminal epidural injection (CPT 64483)?

CPT code 64483 describes "Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level." The code description specifically addresses pain originating from the lumbar or sacral regions by targeting the delivery of medication to the epidural space via a transforaminal approach.

The transforaminal epidural steroid injection is a minimally invasive procedure that targets the specific nerve root causing pain. Unlike other approaches to the epidural space, the transforaminal approach allows for precise delivery of medication to the anterolateral epidural space directly adjacent to the targeted nerve root.

The procedure involves injecting an anesthetic agent and/or steroid into the epidural space through the intervertebral foramen under image guidance (fluoroscopy or CT). This technique allows for direct visualization of contrast flow, confirming appropriate medication placement and avoiding intravascular injection or entry into the cerebrospinal fluid, which could lead to complications.

Transforaminal epidural steroid injections are indicated for patients with:

• Radicular pain from disc herniation
• Spinal stenosis (including osseous stenosis of the neural canal)
• Disc stenosis of neural canal
• Neural canal of lumbar or sacral spine disorders
• Connective tissue and disc stenosis affecting nerve roots
• Subluxation stenosis of intervertebral foramina

These injections for pain management are often considered after conservative treatments have failed but before surgical interventions are pursued, making them a valuable intermediate step in the treatment process.

CPT code 64483 documentation requirements

Proper documentation is essential for accurately coding epidural steroid injections for pain. The patient's medical record must thoroughly demonstrate medical necessity and include specific elements to support the use of this code.

• Patient identification information: Complete demographic information must be documented in compliance with the Social Security Act Title XVIII standard references.
• Diagnostic evidence: The record must contain appropriate ICD-10-CM code(s) supporting the medical necessity of the procedure, such as disc disorders with radiculopathy, stenosis of the neural canal, tissue stenosis of the neural canal, and osseous and subluxation stenosis of the intervertebral foramina.
• Procedural documentation: Coding practices require the documentation of a detailed description of the procedure, confirmation that only one spinal region was treated, documentation of image guidance (fluoroscopy or CT), verification of contrast flow to confirm proper needle placement, and medication type and dosage administered, such as selective nerve root blocks.
• Anatomical specificity: Clear documentation distinguishing between procedures performed in the neural canal of cervical region, neural canal of thoracic region, or neural canal of lumbar region is required, as different CPT codes apply to each spinal region.

CPT code 64483 billing guidelines

Billing and coding epidural injections according to guidelines is crucial for proper reimbursement and compliance with the National Correct Coding Initiative (NCCI).

• Level specificity: Code 64483 represents a single level injection. For additional levels, use add-on code 64484. Each spinal region (cervical, thoracic, lumbar/sacral) has its own primary procedure code.
• Bilateral procedures: When performed bilaterally at the same level, append modifier 50. Document medical necessity for bilateral injections. Be aware that some payers may have specific requirements for reporting bilateral procedures.
• Correct coding initiative considerations: Understand NCCI edits that pair CPT code 64483 with other services. Avoid unbundling services that should be reported together. Review CMS IOM Publication 100 for specific guidance.
• Local coverage determination (LCD) compliance: The LCD reference article for epidural steroid injections often includes utilization parameters (frequency limitations), diagnosis code restrictions, medical necessity criteria, and specific documentation requirements.
• Distinct procedures: CPT code 64483 should not be reported with codes 62321-62323 for the same level on the same day. Different approaches to the epidural space are considered mutually exclusive when treating the same level.