Billing and Coding: Epidural Steroid Injections for Pain Management

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L36920, 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).