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Transforaminal Epidural
Injection was performed
without Imaging or CT
Scan?

How do you bill and
code for this service?
Inclusive with CPT 77003 - Fluoroscopic guidance and localization of
needle or catheter tip for spine or paraspinous diagnostic or therapeutic
injection procedures. (Effective January 01, 2011).

CPT Code 77012 - Computed tomography guidance for needle placement
(eg, biopsy, aspiration, injection, localization device), radiological
supervision and interpretation. (inclusive with the primary procedure
effective January 01, 2011)   

64479 Injection(s), anesthetic agent and/or steroid, transforaminal
epidural;
with imaging guidance (fluoroscopy or CT), cervical or
thoracic, single level
+64480 -cervical or thoracic, each additional level (list separately as add-
on code for primary procedure)

64483 Injection(s), anesthetic agent and/or steroid, transforaminal
epidural;
with imaging guidance (fluoroscopy or CT), lumbar or sacral,
single level
+64484 -lumbar or sacral, each additional level (list separately as add-on
code for primary procedure)


And for your transforaminal epidural injection using ultrasound guidance,
you will use the Category 3 code - 0228T-0231T.

0228T – Injection(s), anesthetic agent and/or steroid, transforaminal
epidural,
with ultrasound guidance, cervical or thoracic; single level
+0229 -each additional level (as add-on code)

0230T – Injection(s), anesthetic agent and/or steroid, transforaminal
epidural,
with ultrasound guidance, lumbar or sacral; single level.
+0231 -each additional level (as add-on code)

Going back to the question, let's look at  what AMA comments:

The AMA published on the Frequently Asked Questions in July 2011 CPT
Assistant
and it was asked there if in this scenario, would a Trigger Point
Injection (20552-20553) be the appropriate codes?.

According to AMA, TFE services must be performed with imaging
guidance. If it is performed
WITHOUT an imaging guidance, and yet the
"intended target was the epidural space via a foramen", the unlisted
code 64999 Nervous System must be reported!

Reference:  CPT Assistant July 2011

Current Procedural Code for 2011, CPT Changes for 2011.


"CPT is owned and is a registered trademark by the American Medical
Association."


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