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LCD Reference Article Billing and Coding Article

Billing and Coding: Epidural Steroid Injections for Pain Management

A56651

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56651
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Epidural Steroid Injections for Pain Management
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 16, Section 180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Section 280.14 Infusion Pumps
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33906, Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.

The services addressed in this article only apply to epidural injections. Other joint procedures (e.g., sacral injections, facet joint) are not addressed.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.

An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).

When CPT codes 62321, 62323, 64479, 64480, 64483 or 64484 are used to report postoperative pain management, the diagnosis code restrictions in this article do not apply when reporting these codes with ICD-10 codes G89.12 (acute post-thoracotomy pain) or G89.18 (other acute postprocedural pain).

If epidural injection (CPT code 62323) is used for an implantable infusion pump trial for severe spasticity, the restrictions in this article do not apply as coverage is determined by NCD 280.14 Infusion Pumps.

When the epidural injection (CPT code 62323) is used for cerebrospinal fluid flow imaging, cisternography (CPT code 78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.

Consistent with the LCD, it is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT codes 62321 and 62323 are not bilateral procedures.

CPT codes 64479 and 64483 are used to report a single level injection. CPT codes 64480 and 64484 represent each additional level, respectively and should be reported separately in addition to the primary procedure when applicable.

A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.

When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.

For services performed in the ASC, modifier -50 should not be utilized. Report the applicable procedure code on two separate lines, with one unit of service each and append the -RT and -LT modifiers to each line.

KX Modifier Requirements

A diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review.

Use of Biologicals

There are currently no U.S. Food and Drug Administration (FDA) approved biologicals for use as an injectable agent into the epidural space or spine. The inclusion of a biological and/or other non-FDA approved substance in the injectant may result in denial of the entire claim based on the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, platelet rich plasma, and vitamins fall into this category.


Utilization Parameters

Only one spinal region may be treated per session (date of service).

Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484 (two unilateral or two bilateral levels). CPT code 64480 should be reported in conjunction with CPT code 64479 and CPT code 64484 should be reported in conjunction with CPT code 64483.

Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.

No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per anatomic region in a rolling 12-month period regardless of the number of levels involved.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. SNRBs and TESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score.
    SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.
  5. Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.
  6. The patient’s medical record should include, but is not limited to:
    • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
    • Relevant medical history.
    • Results of pertinent tests/procedures.
    • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed).
  7. Documentation to support the medical necessity of the procedure(s).

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1

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 Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

(47 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes 62321, 62323, 64479, 64480, 64483, and 64484:

 Group 1 Codes
Code Description
B02.23 Postherpetic polyneuropathy
B02.7 Disseminated zoster
B02.8 Zoster with other complications
B02.9 Zoster without complications
G89.3 Neoplasm related pain (acute) (chronic)
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M48.061 Spinal stenosis, lumbar region without neurogenic claudication
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M96.1 Postlaminectomy syndrome, not elsewhere classified
M99.21 Subluxation stenosis of neural canal of cervical region
M99.22 Subluxation stenosis of neural canal of thoracic region
M99.23 Subluxation stenosis of neural canal of lumbar region
M99.31 Osseous stenosis of neural canal of cervical region
M99.32 Osseous stenosis of neural canal of thoracic region
M99.33 Osseous stenosis of neural canal of lumbar region
M99.41 Connective tissue stenosis of neural canal of cervical region
M99.42 Connective tissue stenosis of neural canal of thoracic region
M99.43 Connective tissue stenosis of neural canal of lumbar region
M99.51 Intervertebral disc stenosis of neural canal of cervical region
M99.52 Intervertebral disc stenosis of neural canal of thoracic region
M99.53 Intervertebral disc stenosis of neural canal of lumbar region
M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region
M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region
M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region
M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region
M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

 Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

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 Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Group 1

Group 1 Paragraph

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 Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/16/2023 R9

Article revised and published on 11/16/2023 in response to an inquiry. The documentation requirement number four was updated.
12/12/2021 R8

Article revised and published on 02/24/2022 effective for dates of service on and after 12/12/2021 to add ICD-10 code M47.26 to the ‘ICD-10-CM Codes that Support Medical Necessity’ section for ‘Group 1 Codes’.
12/12/2021 R7

Article revised and published on 12/9/2021 effective for dates of service on and after 12/12/2021 to provide clarification in response to inquiries. The fourth paragraph in the ‘Utilization Parameters’ section was revised to: No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per anatomic region in a rolling 12-month period regardless of the number of levels involved.
12/12/2021 R6

Article effective for dates of service on and after 12/12/2021.

Draft article posted on 6/10/2021.
10/01/2021 R5

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to the article: C56.3, C79.63, M54.59 in Group 1 Codes. The following ICD-10-CM code has been deleted and therefore has been removed from the article: M54.5 in Group 1 Codes.
01/01/2021 R4

Article revised and published on 03/11/2021. The Part A Contractor ID numbers 09101 and 09201 have been removed as they were inadvertently added with a prior revision.
01/01/2021 R3

Article revised and published on 2/11/2021 effective for dates of service on and after 01/01/2021 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT codes either the short description and/or the long description was changed: 64479, 64480, 64483, and 64484 in Group 1 CPT Codes. Minor formatting changes made throughout coding section.
06/04/2020 R2

Revision Number: 2
Publication: June 2020 Connection
LCR B2020-010

Explanation of Revision: Based on review of the LCD, a decision was made to remove CPT codes 62321 and 62323 from the "ICD-10 Codes that Support Medical Necessity/Group 1 Paragraph:" section of this billing and coding article. In addition, the "CPT/HCPCS Codes/Group 1 Paragraph:" section of the billing and coding article was revised to add the following language: "The following CPT codes will not have diagnosis to procedure code limitations applied at this time: 62320, 62321, 62322, and 62323". The effective date of this revision is based on process date.
10/01/2019 R1

Revision Number: 1
Publication: September 2019 Connection
LCR B2019-022

Explanation of Revision: Based on CR 11322 (Annual 2020 ICD-10-CM Update) the billing and coding article was revised. The descriptor was revised for ICD-10-CM diagnosis code M50.120. The effective date of this revision is for dates of service on or after 10/01/2019.

Also, based on review of the billing and coding article, formatting errors were identified and corrected. The frequency limitations information was removed from the “Utilization Guidelines” section of the Billing and Coding article and placed into the “Limitations” section of the LCD. The effective date of this revision is for dates of service on or after 10/01/19.

In addition, the following unspecified ICD-10-CM diagnosis codes were removed as it is the provider’s responsibility to code to the highest level of specificity: C31.9, C34.00, C34.10, C34.30, C34.80, C34.90, C34.91, C34.92, C40.00, C40.10, C40.20, C40.30, C40.80, C40.90, C40.91, C40.92, C43.10, C43.20, C43.30, C43.60, C43.70, C43.9, C4A.10, C4A.20, C4A.30, C4A.60, C4A.70, C4A.9, C44.00, C44.101, C44.1021, C44.1022, C44.1091, C44.1092, C44.111, C44.121, C44.131, C44.191, C44.201, C44.202, C44.209, C44.211, C44.221, C44.291, C44.300, C44.301, C44.309, C44.310, C44.320, C44.390, C44.40, C44.500, C44.501, C44.509, C44.601, C44.602, C44.609, C44.611, C44.621, C44.691, C44.701, C44.702, C44.709, C44.721, C44.791, C44.80, C44.90, C44.91, C44.92, C44.99, C45.9, C49.10, C49.20, C49.9, C49.A0, C50.019, C50.029, C50.119, C50.129, C50.219, C50.229, C50.319, C50.329, C50.419, C50.429, C50.519, C50.529, C50.619, C50.629, C50.819, C50.829, C50.919, C50.929, C51.9, C53.9, C54.9, C56.9, C57.00, C57.10, C57.20, C57.9, C60.9, C62.00, C62.10, C62.90, C62.91, C62.92, C63.00, C63.10, C63.9, C64.9, C65.9, C66.9, C68.9, C69.00, C69.10, C69.20, C69.30, C69.40, C69.50, C69.60, C69.80, C69.90, C69.91, C69.92, C70.9, C71.9, C72.20, C72.30, C72.40, C72.50, C72.9, C74.00, C74.10, C74.90, C74.91, C74.92, C75.9, C7A.00, C7A.094, C7A.095, C7A.096, C76.40, C76.50, C76.8, C78.00, C78.30, C78.80, C79.00, C79.10, C79.40, C79.60, C79.70, C79.9, C81.10, C81.20, C81.30, C81.40, C81.70, C81.90, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C82.00, C82.10, C82.20, C82.30, C82.40, C82.50, C82.60, C82.80, C82.90, C82.91, C82.92, C82.93, C82.94, C82.95, C82.96, C82.97, C82.98, C82.99, C83.00, C83.10, C83.30, C83.50, C83.70, C83.80, C83.90, C84.00, C84.10, C84.40, C84.60, C84.A0, C84.Z0, C84.90, C84.91, C84.92, C84.93, C84.94, C84.95, C84.96, C84.97, C84.98, C84.99, C85.10, C85.20, C85.80, C85.90, C85.91, C85.92, C85.93, C85.94, C85.95, C85.96, C85.97, C85.98, C85.99, C88.9, C96.20, D01.40, D01.9, D02.20, D02.4 D03.10, D03.20, D03.30, D03.60, D03.70, D03.9, D04.10, D04.20, D04.30, D04.60, D04.70, D04.9, D05.00, D05.10, D05.80, D05.90, D05.91, D05.92, D06.9, D07.30, D07.60, D09.10, D09.20, D09.8, D09.9, D10.30, D11.9, D12.6, D13.30, D13.9, D14.30, D15.9, D16.00, D16.10, D16.20, D16.30, D16.9, D17.20, D17.30, D17.9, D18.00, D19.9, D21.10, D21.20, D22.10, D22.20, D22.30, D22.60, D22.70, D23.10, D23.20, D23.30, D23.60, D23.70, D23.9, D24.9, D26.9, D27.9, D28.9, D29.20, D29.30, D29.9, D30.00, D30.10, D30.20, D30.9, D31.00, D31.10, D31.20, D31.30, D31.40, D31.50, D31.60, D31.90, D32.9, D33.9, D35.00, D35.9, D36.9, D3A.00, D3A.094, D3A.095, D3A.096, D37.039, D37.9, D38.6, D39.10, D39.9, D40.10, D40.9, D41.00, D41.10, D41.20, D41.9, D43.2, D43.9, D44.10, D44.9, D46.9, D47.9, D48.60, D48.9, D49.519, D49.9, E10.40, E11.40, E13.40, G56.00, G56.10, G56.20, G56.30, G56.40, G56.80, G56.90, G56.91, G56.92, G56.93, G57.40, G57.70, G57.80, G80.9, G81.10, G83.30, G83.9, G90.50, G90.519, G90.529, G95.20, M05.519, M05.529, M05.539, M05.549, M05.559, M05.569, M05.579, M43.20, M48.00, M48.50XA, M48.50XD, M48.50XG, M48.50XS, M50.00, M50.10, M50.20, M50.30, M53.9, M54.30, M54.40, M54.9, Q85.00, R52, S14.109S, S14.119S, S14.129S, S14.139S, S14.149S, S14.159S, S24.109S, S24.119S, S24.139S, S24.149S, S24.159S, S34.109S, S34.119S, and S34.129S. The effective date of this revision is for dates of service on or after 11/12/2019.
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