LCD Reference Article Billing and Coding Article

Billing and Coding: Epidural Steroid Injections for Pain Management

A58993

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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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General Information

Source Article ID
N/A
Article ID
A58993
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
06/19/2022
Revision Effective Date
11/15/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Section 280.14 Infusion Pumps
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

 

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39240-Epidural Steroid Injections 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 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 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 restriction 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.

CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). CPT codes 64480 and 64484 represent each additional level respectively and should be reported separately in addition to the primary procedure when applicable.

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

Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two 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 one 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 blocks along with the pre and post percent (%) pain relief achieved immediately post-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 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

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Coding Information

Bill Type Codes

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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(46 Codes)
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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 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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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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

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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

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Other Coding Information

Group 1

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Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
11/15/2023 R3

Revision Effective DOS 11/15/2023

Editorial updates made under "Coding Guidance" and "Utilization Parameters."

Added verbiage to Documentation Requirements #4.

11/06/2022 R2

Updated to indicate this article is an LCD Reference Article.

11/06/2022 R1

Revision Effective: 11/06/2022
Revision Explanation: Updated information for ASC to remind providers they should still use modifier 50 and added the paragraph for moderate sedation.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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