Healthcare Coding: Accurately Documenting Transforaminal Injection


Your transforaminal injection may be called a selective nerve root block by your providers. Currently, we only have one code or one set of codes. We do not and have a code for a nerve root block if they don’t actually go all the way in through the epidural space. However, when they inject that nerve root right at the foramen, that medication will go into the epidural space usually or it may.

Healthcare Coding Update:

Back in the year 2000 or 1999, we had paravertebral nerve blocks. When they created the new codes, when the AMA created these new transforaminal codes, they just said that we were to use the codes for transforaminal injection instead of those paravertebral.

So what this is it's an injection around a specific nerve root which really enables a doctor to determine whether or not that that nerve root is the cause of the patient’s pain. Most often, it will be used for diagnostic purposes. Sometimes it will be used for therapeutic purposes.

Obviously, if it helps the pain, we’d never know, you never know how long that therapy or that therapeutic reaction is going to stay either, different in different people. One per patient may get relief for two days and another may get relief for a longer period of time.

It would be almost unheard of for a procedure such as a transforaminal epidural to be performed without using imaging. So, fluoroscopic guidance is not included, not bundled into the code and the code for that is 77003.

The translaminar epidural maybe done without fluoral or any other kind of radiological imaging because anesthesiologists have been doing that for years. Although in chronic pain management, the physicians are generally trying to target a very specific area and thereby, they're using more frequently, they will use fluoroscopy.

The codes for a transforaminal epidural, 64479 of course is the first or single level. Then 64480 and that's your cervical or thoracic and your lumbar/sacral are your 64483 and 64484.

Let's talk a little bit about these medical coding and billing options. First of all, they are unilateral injections. It means that these codes are set up to do the injection on one side of the body. When two sides of the body are injected, a mirror image, the same nerve root or same foramen on the left and right, that is going to be a 50 modifier, it's a bilateral injection.

These codes are modifier 51 exempt. This means two things. First of all, you should not append a 50 modifier to these additional level codes. When a code reads each additional level, it cannot be billed until you bill that parent code.

So your parent codes are 64479 and 64483. You must bill one of those codes first. And then you bill each additional level. That also means it's appropriate to bill as many levels as the doctor actually injects. So if a physician injects L3-4, you bill 644783 and L4-L5, you would bill 64484. And then should the doctor go down to L5-S1, you will bill 64484 again.

From the CPT healthcare coding perspective, no modifier except the 50 modifier would actually be appended if you did the bilateral. For unilateral multiple level injection, a modifier is not needed and should not be reported except – nowadays, we have an except for everything – your third party payer may not be able to process a claim with these each additional levels. That's because they don’t understand the codes and they don’t know how to program their computers.

But that becomes our problem in billing because if your provider does a three level injection, unilateral or bilateral, you should be paid the appropriate amount of money. Thereby, your payer may require a modifier and they probably won't tell you what modifier. But they may want a 76. They may even want a 51 heaven forbid. And they may want a 59.

So, you really need to watch your payments that come in. There are two rules here, know how much you're supposed to be paid. That's number one. Number two is know that you were paid that amount of money. And if you have to go back and appeal and append the modifier that the AMA wouldn't really recommend, the AMA recognizes that third party payers make up their own rules.

And if you read the CPT healthcare coding articles, you will see time and time again, the AMA refers to other payers may have their own rules. So you have to bill the way your payer wants you to bill to get paid appropriately.

What you don’t want to do is bill in such a manner that you get less money or too much. You don’t want too much or too little. You want what you're supposed to be paid.

Now your bilateral. Suppose, if the doctor injected separate nerve roots, a root at C6 which is a spinal level and a root at C7 which is a spinal level, and if the injection were a bilateral injection, you would report 64479 with the 50 x 1, 64479 with a 50 x 1 – 80, we mean with a 50.

Now, if you had three levels here, yes, you can report multiple units of service but you would want to again, watch your payments carefully to be sure that you got paid on those additional levels, you would get paid at two units of service.

Your fluoroscopic guidance, one of the concerns of course in using the fluoroscopy is that the medication won't reach that target level. And you definitely need to use fluoroscopy for transforaminal. More often, physicians are using it in chronic pain for the translaminar also.  An epidurogram during your initial injection, the first time you inject it in the epidural space may be warranted. Fluoral guidance is bundled into all of these codes. So you want to be careful with that and make sure documentation supports it for error free medical coding and billing.

To keep yourself updated with the medical coding guidelines, visit our medical coding training online page.