Epidural Steroid Injection

Epidural Steroid Injection

Epidural steroid injection involves injection of an anesthetic agent along with a steroid into the epidural space to relieve pain.

Injecting steroid can decrease inflammation associated with common conditions such as spinal stenosis, disc herniation, or degenerative disc disease.

CPT 62310 and 62311 are usually used to describe epidural injection procedures from a caudal
approach. 

Fluoroscopy is reported separately with Code 77003 and is coded once per session. 

*Therefore, if two cervical and one thoracic level were treated, code 77003 would be used only once
CPT : 62310 - Injections, of diagnostic or therapeutic substances (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician uses fluoroscopic guidance to advance a needle into the skin, focusing it toward the epidural space. The physician injects a contrast material to confirm the location of the needle, taking care to avoid any injury to the nearby nerve roots and spinal cord. The physician injects epidural steroid solution and monitors the patient for 15–20 minutes after the injection. After the procedure, the provider extracts the needle, flushes the site with sterile saline, and applies gauze over the site of needle insertion.

CPT : 62311 - Injections, of diagnostic or therapeutic substances (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) 

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician uses fluoroscopy guidance, a needle is inserted into the skin and directed toward the epidural space. Once the needle is in the proper position, contrast is injected to confirm the needle location. The epidural steroid solution is then injected. Following the injection, the patient is monitored for 15 to 20 minutes.  After the procedure, the provider extracts the needle, flushes the site with sterile saline, and applies gauze over the site of needle insertion.

There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x–ray) guidance. An interlaminar ESI, often referred to simply as an ‘epidural injection', involves placing the needle into the back of the epidural space and delivering the steroid over a wider area.The caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space.

Note:
Injection of small amount of contrast to confirm the needle position is part of the procedure and its not coded separately.