Coding and Compliance: Expert Epidural Steroid Injection Tips for Successful Claims


The next time you code an epidural steroid injection (ESI), take a closer look at your claim. You could be losing up to $86 if you miss an opportunity to report fluoroscopy code 77003. Use this comprehensive look at coding pain management ESI encounters to be sure you’re on a road to successful medical coding and billing claims.

Start With 62310-62311

The physician likely will choose an interlaminar epidural approach, placing the medicine inside the epidural space. As long as the needle is positioned in the epidural or subarachnoid space with the needle [inserted] ‘straight’ in between the lamina, then the following are the correct medical coding and billing options:

  • 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic,opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
  • 62311 -- …lumbar, sacral (caudal).

Coding and Compliance Tip:

Be careful not to confuse single injection codes 62310-62311 with the following continuous infusion or intermittent bolus codes:

  • 62318 -- Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
  • 62319 -- … lumbar, sacral (caudal).

Watch for Transforaminal Approach

If the physician inserts the needle at an angle into the intervertebral foramen to perform an injection at the nerve root area this is a transforaminal (through the foramen) epidural injection.

With this type of epidural, the physician injects the medication into the lateral epidural space "bathing" a specific spinal nerve as it exits the spinal cord. For this approach, you’d use a different set of codes, as follows:

  • 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level
  • +64480 -- … cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
  • 64483 -- … lumbar or sacral, single level
  • +64484 -- … lumbar or sacral, each additional level (list separately in addition to code for primary procedure).

Add-on medical coding rules:

You should report 64479 and 64483 as the primary codes for the first transforaminal injection to the cervical/thoracic or lumbar/sacral levels, respectively. Use add-on codes 64480 and 64484 for each additional injection at the cervical/thoracic or lumbar/sacral levels, respectively.

Example: The physician administers transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces, two different levels. You should report 64483 for the first lumbar injection and 64484 for the additional level injection.

Medical Billing and Coding Training Tip: Find Out if You Qualify for Fluoro Code

Increasingly, physicians are using imaging guidance to verify precise needle placement for the ESI. You may report fluoroscopic guidance separately with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

The 2008 Medicare physician fee schedule lists an allowable reimbursement range of approximately $50 to $86 for 77003 (global service), depending on where your office is geographically located.

Watch for: The physician needs to include documentation that he used fluoroscopic guidance for the procedure

For more healthcare coding updates and information, visit our medical coding conference page.