This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39242-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 the epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.
When epidural injections (62321, 62323, 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restriction in this article do not apply.
When epidural injection (62323) is used for an implantable infusion pump trial, the diagnosis code restrictions in this article do not apply.
CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). 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, physicians must continue to use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.
It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.
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. Aberrant use of the -KX modifier may trigger focused medical review.
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). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 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 spinal 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. Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.
5. Films that adequately document (minimum of 2 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.)
- Documentation to support the medical necessity of the procedure(s).
Use of Biologicals
There are currently no FDA approved biologicals for use as injectable agents into the epidural space or spine. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.
