Nerve Root Blocks

Nerve Root Blocks (Transforaminal Epidural Injection)

Nerve root blocks involve the selective injection of anesthetic agent and steroids via a transforaminal
approach adjacent to a nerve root to relieve pain in that nerve root distribution. This also describes
the transforaminal approach to epidural steroid injection at a localized level. This approach
may be performed after failed caudal epidural steroid injection therapy.

Procedure Description:

A cervical or thoracic transforaminal injection is commonly performed in cases of radiculopathy or radiculitis. Under the guidance of a fluoroscope, the physician identifies the cervical or thoracic vertebrate and its nerve root. The skin and subcutaneous tissue are anesthetized. A contrast material is injected to identify the area of the joint in relation to the needle tip. Then the physician administers a combination of anesthetic and steroid medication into the neuroforaminal epidural space.

Nerve Root Blocks - Cervical or Thoracic,

 

CPT 64479 - Injections, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 

CPT 64480 - Injections, anesthetic agent 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) 

Nerve Root Blocks -  Lumbar or Sacral

CPT 64483 - Injections, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 

CPT 64484 - Injections, anesthetic agent 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) 

Notes:

These codes are per level, per side treated. If one side is treated in a region, use the code once. If both sides are treated, use 50 modifier.

Do not use code 77003, 77012, or 76942, as guidance is bundled for transforaminal epidural
injections

Use codes 0228T-0231T for transforaminal epidural injections using ultrasound guidance.

0228T -  Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level 

0229T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) 

0230T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 

0231T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Use unlisted code 22899 for injection of an anesthetic/steroid combination into a synovial cyst
via a laminar osteotomy.

Facet Injections

Facet Injections

Facet injections involve injection of an anesthetic agent or a steroid into the facets of the spine to relieve pain.

Facet Injections CPT Codes for cervical or thoracic level,

For the first level in the cervical or thoracic region, report 64490

For a second level in the cervical or thoracic region, report add on code 64491

For the third level and beyond, report add on code 64492.

CPT : 64490 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level.

Procedure Description:

The physician preps and anesthetizes the patient for a facet joint injection. The physician then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis. 

CPT : 64491 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 

CPT : 64492 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Do not separately code for multiple injections at the same spinal level. 

Report code 64490 once for the first level, example C3 to C4, 

Report add on code 64491 once for the second level, example C4 to C5, and 

Report add on code 64492 once for any additional levels.

Facet Injections CPT Codes for lumbar or sacral,

For the first level in the lumbar or sacral, report 64493

For a second level in the cervical or thoracic region, report add on code 64494

For the third level and beyond, report add on code 64495. 

CPT : 64493 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 

Procedure Description:  

In this service, the physician preps and anesthetizes the patient for a facet joint injection. The physician then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis.

CPT : 64494 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) 

CPT : 64495 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 

Do not separately code for multiple injections at the same spinal level. 

Report code 64493 once for the first level, example L3 to L4, 

Report add on code 64494 once for the second level, example L4 to L5, and 

Report add on code 64495 once for any additional levels.

Notes:

If one side is treated in a region, use the code once. If both sides are treated, Use a 50 modifier.

Fluoroscopy or CT guidance are bundled into facet blocks. 

Injection of small amount of contrast to confirm the needle position is also included can not be coded separately.

Use codes 0213T-0218T for ultrasound guided facet or medial nerve root blocks.

Use unlisted code 64999 to describe injection of botulism toxin into a facet joint.

Use unlisted code 64999 for injecting an anesthetic agent around implanted spinal hardware.

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.

Intervertebral Disc Aspiration

Intervertebral Disc Aspiration

Intervertebral disc aspiration involves placement of a needle into the disc space with aspiration, and
washings, in an attempt to gain enough sample to evaluate for the possibility of disc infection. 

CPT 62267 - Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes.

For imaging, use 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).

Procedure Description:

The physician positions the patient on his side or lying face down and after prepping and draping the patient, administers a local anesthetic at the proposed puncture site. Using fluoroscopy or computed tomography imaging guidance, the physician then introduces a hollow needle into the spinal column at the puncture site. then advances the needle until she positions it in the disc or in the surrounding tissue. Then he verifies the needle placement using CT or fluoroscopic imaging then uses the needle to aspirate fluid and or cells, moving the needle and taking samples as necessary. he sends samples to the laboratory for diagnostic testing. Finally, he withdraws the needle and applies a sterile dressing.

CPT 62287 - Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injections at the treated levels, when performed, single or multiple levels, lumbar

Procedure Description:

Patient is appropriately prepped and anesthetized, the physician uses one of several methods to decompress or remove disc material from a disc that is protruding through two or more vertebrae in the lumbar portion of the spine. In any method, using fluoroscopy, the physician injects contrast into the gel like center, or nucleus, of the suspect spinal disc to better visualize the disc and protruding material, known as discography. The physician also uses an endoscope and fluoroscopy guidance, along with a local epidural anesthetic injection, to perform a lumbar decompression. In this procedure, the physician places the patient on a radiolucent table and inserts a needle through a stab wound in the flank, or side of the patient and guides the needle into the disc interspace, being careful not to puncture the dura. After puncturing the disc, he confirms the proper positioning of the needle using fluoroscopic images. Next, he either manually, or using an automated device, radiofrequency, or laser energy, aspirates disc tissue, removing as much material as he safely can until he decompresses the nerve.

Note:

If deep bone biopsy of the vertebral body end plate and percutaneous disc aspiration are performed
at the same level, use code 20225 to describe the procedure. Do not use code 62267 in this case.

Do not use code 62267 with codes for Fine needle aspiration (10022), deep bone biopsy (20225), therapeutic disc decompression (62287), or discography (62290, 62291).

Use code 62287 when the physician is performing a therapeutic removal of disc material percutaneously to ease symptoms of disc compression of adjacent nerves. Code 62287 is used only
once, regardless of the number of levels treated at one session.

Do not report 62287 in conjunction with 62267, 62290, 62311, 77003, 77012, 72295, when performed at same level.