Billing and Coding: Epidural Steroid Injections for Pain Management

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L39054 Epidural Procedures 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 join) 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 restrictions 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.

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
2 separate lines, with 1 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 1 spinal region may be treated per session (date of service).

Consistent with the LCD, only 2 total levels per session are allowed for CPT
codes 64479, 64480, 64483 and 64484. (2 unilateral or 2 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 1
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 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 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 agent
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.