LCD Reference Article Billing and Coding Article

Billing and Coding: Epidural Steroid Injections for Pain Management

A58695

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A58695
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Epidural Steroid Injections for Pain Management
Article Type
Billing and Coding
Original Effective Date
12/05/2021
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §280.14 Infusion Pumps

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §20.9 National Correct Coding Initiative (NCCI)

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Epidural Steroid Injections for Pain Management L38994.

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 Outpatient Prospective Payment System (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 1 line with 1 unit of service. For bilateral procedures regarding these same codes, use 1 line and append the modifier -50.

For services performed in the ambulatory surgery center (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® codes 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 Food and Drug Administration (FDA)-approved biologicals for use as injectable agents 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.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT® codes in their CPT® book.

Group 1 Codes
Code Description
62321 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
62323 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)
64479 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, SINGLE LEVEL
64480 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64483 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL
64484 INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Group 2

(2 Codes)
Group 2 Paragraph

These codes are not medically reasonable and necessary for pain management procedures.

Group 2 Codes
Code Description
62320 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE
62322 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITHOUT IMAGING GUIDANCE
N/A

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

 

Group 1 Codes
Code Description
50 BILATERAL PROCEDURE: UNLESS OTHERWISE IDENTIFIED IN THE LISTINGS, BILATERAL PROCEDURES THAT ARE PERFORMED AT THE SAME OPERATIVE SESSION SHOULD BE IDENTIFIED BY ADDING THE MODIFIER -50 TO THE APPROPRIATE FIVE DIGIT CODE OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09950
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
LT LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
RT RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(46 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT® codes 62321, 62323, 64479, 64480, 64483, and 64484:

Group 1 Codes
Code Description
B02.23 Postherpetic polyneuropathy
B02.7 Disseminated zoster
B02.8 Zoster with other complications
B02.9 Zoster without complications
G89.3 Neoplasm related pain (acute) (chronic)
M47.22 Other spondylosis with radiculopathy, cervical region
M47.23 Other spondylosis with radiculopathy, cervicothoracic region
M47.24 Other spondylosis with radiculopathy, thoracic region
M47.25 Other spondylosis with radiculopathy, thoracolumbar region
M47.26 Other spondylosis with radiculopathy, lumbar region
M47.27 Other spondylosis with radiculopathy, lumbosacral region
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M51.14 Intervertebral disc disorders with radiculopathy, thoracic region
M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region
M51.16 Intervertebral disc disorders with radiculopathy, lumbar region
M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region
M54.12 Radiculopathy, cervical region
M54.13 Radiculopathy, cervicothoracic region
M54.14 Radiculopathy, thoracic region
M54.15 Radiculopathy, thoracolumbar region
M54.16 Radiculopathy, lumbar region
M54.17 Radiculopathy, lumbosacral region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M96.1 Postlaminectomy syndrome, not elsewhere classified
M99.21 Subluxation stenosis of neural canal of cervical region
M99.22 Subluxation stenosis of neural canal of thoracic region
M99.23 Subluxation stenosis of neural canal of lumbar region
M99.31 Osseous stenosis of neural canal of cervical region
M99.32 Osseous stenosis of neural canal of thoracic region
M99.33 Osseous stenosis of neural canal of lumbar region
M99.41 Connective tissue stenosis of neural canal of cervical region
M99.42 Connective tissue stenosis of neural canal of thoracic region
M99.43 Connective tissue stenosis of neural canal of lumbar region
M99.51 Intervertebral disc stenosis of neural canal of cervical region
M99.52 Intervertebral disc stenosis of neural canal of thoracic region
M99.53 Intervertebral disc stenosis of neural canal of lumbar region
M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region
M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region
M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region
M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region
M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region
M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.


Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/16/2023 R3

Under CMS National Coverage Policy added the following regulation: “CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.” Under Article Text subheading Documentation Requirements #4 verbiage was revised to “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.” Acronyms were defined where appropriate throughout the article. Formatting, punctuation and typographical errors were corrected throughout the article.

11/06/2022 R2

Under Article Text revised verbiage regarding physician use of modifier 50 when services are performed in an ASC, and added language regarding the use of moderate or deep sedation, general anesthesia, and monitored anesthesia (MAC).

12/05/2021 R1

Under Article Text – Utilization Parameters revised the verbiage in the latter portion of the fourth sentence to read “…may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved”. Under ICD-10-CM Codes that Support Medical Necessity – Group 1: Codes deleted code M48.061.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L38994 - Epidural Steroid Injections for Pain Management
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/07/2023 11/16/2023 - N/A Currently in Effect You are here
09/15/2022 11/06/2022 - 11/15/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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