How To Use CPT Code 64479

CPT 64479 refers to the injection of an anesthetic agent and/or steroid in a transforaminal epidural, with imaging guidance, at a single cervical or thoracic level. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 64479.

1. What is CPT 64479?

CPT 64479 is a medical procedure code used to describe the injection of an anesthetic agent and/or steroid in the form of a transforaminal epidural injection into a single level (either cervical or thoracic) with the assistance of imaging guidance, such as fluoroscopy or computed tomography (CT).

2. 64479 CPT code description

The official description of CPT code 64479 is: “Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level.”

3. Procedure

1. The patient is positioned appropriately for the procedure, either lying face down or on their side.
2. Imaging guidance, such as fluoroscopy or CT, is used to identify the target cervical or thoracic vertebrae and its nerve root.
3. The skin and subcutaneous tissue over the target area are anesthetized using a local anesthetic.
4. A needle is carefully inserted through the anesthetized area and advanced towards the neuroforaminal epidural space, under continuous imaging guidance.
5. Once the needle is in the correct position, a contrast material is injected to confirm accurate needle placement and to visualize the area of the joint in relation to the needle tip.
6. The provider then administers the anesthetic agent and/or steroid (e.g., triamcinolone and methylprednisolone) into the targeted nerve root within the neuroforaminal epidural space.
7. After the injection, the needle is removed, and the injection site is cleaned and dressed.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 64479 services typically suffer from conditions such as radiculopathy or radiculitis, which cause pain, numbness, or weakness in the cervical or thoracic regions. These conditions may result from nerve compression due to herniated discs, spinal stenosis, or other spinal abnormalities. The procedure aims to alleviate pain and inflammation by delivering an anesthetic agent and/or steroid directly to the affected nerve root.

5. When to use CPT code 64479

It is appropriate to bill the 64479 CPT code when a provider performs a single-level transforaminal epidural injection in the cervical or thoracic region, with imaging guidance, to treat conditions such as radiculopathy or radiculitis. The code should only be used for a single level injection; additional levels require the use of add-on codes.

6. Documentation requirements

To support a claim for CPT 64479, the following information should be documented in the patient’s medical record:

• Patient’s medical history and physical examination findings, including symptoms and duration of pain.
• Diagnosis and indication for the procedure, such as radiculopathy or radiculitis.
• Details of the procedure, including the specific cervical or thoracic level targeted, type of imaging guidance used, and the anesthetic agent and/or steroid injected.
• Post-procedure assessment, including any immediate pain relief or adverse reactions.
• Follow-up plan, including any additional treatments or referrals if necessary.

7. Billing guidelines

When billing for CPT code 64479, it is essential to follow the appropriate guidelines and rules. Use CPT code 64479 for a single level injection in the cervical or thoracic area. For bilateral procedures, report the relevant codes with modifier 50. Additionally, if multiple levels are treated, use the appropriate add-on codes for each additional level.

8. Historical information

CPT 64479 was added to the Current Procedural Terminology system on January 1, 2000. The code has undergone changes in its descriptor over the years, with the most recent change occurring on January 1, 2021.

9. Similar codes to CPT 64479

Five similar codes to CPT 64479 include:

• CPT 64480: This code is used for additional levels of cervical or thoracic transforaminal epidural injections, with imaging guidance.
• CPT 64483: This code is for a single level injection in the lumbar or sacral region, with imaging guidance.
• CPT 64484: This code is used for additional levels of lumbar or sacral transforaminal epidural injections, with imaging guidance.
• CPT 62320: This code is for a single injection of an anesthetic agent and/or steroid in the cervical or thoracic region, without imaging guidance.
• CPT 62322: This code is for a single injection of an anesthetic agent and/or steroid in the lumbar or sacral region, without imaging guidance.

10. Examples

1. A 45-year-old patient with cervical radiculopathy due to a herniated disc receives a CPT 64479 transforaminal epidural injection at the C5-C6 level, with fluoroscopic guidance.
2. A 60-year-old patient with thoracic radiculitis caused by spinal stenosis undergoes a CPT 64479 transforaminal epidural injection at the T7-T8 level, using CT guidance.
3. A 50-year-old patient with cervical radiculopathy resulting from foraminal stenosis receives a CPT 64479 transforaminal epidural injection at the C6-C7 level, with fluoroscopic guidance.
4. A 55-year-old patient with thoracic radiculitis due to degenerative disc disease undergoes a CPT 64479 transforaminal epidural injection at the T5-T6 level, using CT guidance.
5. A 65-year-old patient with cervical radiculopathy caused by osteophyte formation receives a CPT 64479 transforaminal epidural injection at the C4-C5 level, with fluoroscopic guidance.
6. A 70-year-old patient with thoracic radiculitis resulting from facet joint arthritis undergoes a CPT 64479 transforaminal epidural injection at the T9-T10 level, using CT guidance.
7. A 40-year-old patient with cervical radiculopathy due to a foraminal cyst receives a CPT 64479 transforaminal epidural injection at the C3-C4 level, with fluoroscopic guidance.
8. A 75-year-old patient with thoracic radiculitis caused by a synovial cyst undergoes a CPT 64479 transforaminal epidural injection at the T11-T12 level, using CT guidance.
9. A 35-year-old patient with cervical radiculopathy resulting from a nerve sheath tumor receives a CPT 64479 transforaminal epidural injection at the C7-T1 level, with fluoroscopic guidance.
10. A 80-year-old patient with thoracic radiculitis due to a compression fracture undergoes a CPT 64479 transforaminal epidural injection at the T3-T4 level, using CT guidance.