How To Use CPT Code 64484

CPT 64484 refers to the injection of an anesthetic agent and/or steroid in a transforaminal epidural in the lumbar or sacral region, with imaging guidance. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 64484 procedures.

1. What is CPT 64484?

CPT 64484 is a medical billing code used to describe the injection of an anesthetic agent and/or steroid in the form of a transforaminal epidural injection in the lumbar or sacral region, with imaging guidance. This code is applicable for each additional level after the initial level. The procedure is commonly performed in cases of lower back pain or radiculitis.

2. 64484 CPT code description

The official description of CPT code 64484 is: “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)”.

3. Procedure

The 64484 procedure involves the following steps:

  1. Identification of the lumbar or sacral vertebrae and its nerve root using fluoroscopy or computed tomography (CT) guidance.
  2. Anesthetizing the skin and subcutaneous tissue.
  3. Injection of contrast material to identify the area of the joint in relation to the needle tip (e.g., loss of resistance technique).
  4. Administration of an anesthetic and/or steroid (e.g., triamcinolone and methylprednisolone) into the neuroforaminal epidural space (targeted nerve root).
  5. This injection is for an additional level following injection at the initial level.

4. Qualifying circumstances

Patients eligible to receive CPT code 64484 services are those experiencing lower back pain or radiculitis, which may be caused by conditions such as herniated discs, spinal stenosis, or degenerative disc disease. The procedure is typically performed when conservative treatments, such as physical therapy or medication, have not provided adequate relief. A healthcare provider will determine if a patient is a suitable candidate for the procedure based on their medical history, symptoms, and imaging studies.

5. When to use CPT code 64484

It is appropriate to bill the 64484 CPT code when a provider performs a transforaminal epidural injection in the lumbar or sacral region, with imaging guidance, for each additional level after the initial level. The code should be used in conjunction with the primary procedure code (e.g., 64483) and reported separately. The procedure is typically performed to alleviate lower back pain or radiculitis that has not responded to conservative treatments.

6. Documentation requirements

To support a claim for CPT 64484, the following information should be documented:

  • Patient’s medical history, including symptoms and previous treatments.
  • Physical examination findings.
  • Imaging studies, such as MRI or CT scans, that support the need for the procedure.
  • Details of the procedure, including the specific lumbar or sacral level(s) targeted, type of anesthetic agent and/or steroid used, and imaging guidance method (fluoroscopy or CT).
  • Post-procedure assessment, including any immediate pain relief or complications.
  • Follow-up plan, including any additional treatments or referrals.

7. Billing guidelines

When billing for CPT code 64484, it is important to remember that it is an add-on code and must be reported with an appropriate primary code, such as 64483. Payers will not reimburse for 64484 unless it is reported with a primary code. Additionally, 64484 should be reported for each additional level after the initial level. For bilateral procedures, report 64483 with modifier 50. Imaging guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of 64479-64484 and should not be billed separately.

8. Historical information

CPT 64484 was added to the Current Procedural Terminology system on January 1, 2000. The code has undergone two changes since its addition:

  • On January 1, 2011, the descriptor was changed to “Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)”.
  • On January 1, 2021, the descriptor was updated to its current form.

9. Similar codes to CPT 64484

Five similar codes to CPT 64484 and how they differentiate are:

  • CPT 64479: This code is used for a single-level transforaminal epidural injection in the cervical or thoracic region, with imaging guidance.
  • CPT 64480: This code is used for each additional level after the initial level for a transforaminal epidural injection in the cervical or thoracic region, with imaging guidance.
  • CPT 64483: This code is used for a single-level transforaminal epidural injection in the lumbar or sacral region, with imaging guidance.
  • CPT 62320: This code is used for a single-level interlaminar epidural injection in the cervical or thoracic region, without imaging guidance.
  • CPT 62322: This code is used for a single-level interlaminar epidural injection in the lumbar or sacral region, without imaging guidance.

10. Examples

Here are 10 detailed examples of CPT code 64484 procedures:

  1. A patient with chronic lower back pain and radiculopathy due to lumbar disc herniation undergoes transforaminal epidural injections at L4-L5 and L5-S1 levels, with fluoroscopic guidance.
  2. A patient with lumbar spinal stenosis receives transforaminal epidural injections at L3-L4 and L4-L5 levels, with CT guidance.
  3. A patient with degenerative disc disease undergoes transforaminal epidural injections at L2-L3, L3-L4, and L4-L5 levels, with fluoroscopic guidance.
  4. A patient with lumbar radiculopathy due to foraminal stenosis receives transforaminal epidural injections at L5-S1 and S1-S2 levels, with CT guidance.
  5. A patient with failed back surgery syndrome undergoes transforaminal epidural injections at L4-L5 and L5-S1 levels, with fluoroscopic guidance.
  6. A patient with lumbar facet joint syndrome receives transforaminal epidural injections at L3-L4 and L4-L5 levels, with CT guidance.
  7. A patient with lumbar spondylolisthesis undergoes transforaminal epidural injections at L5-S1 and S1-S2 levels, with fluoroscopic guidance.
  8. A patient with lumbar radiculopathy due to synovial cysts receives transforaminal epidural injections at L4-L5 and L5-S1 levels, with CT guidance.
  9. A patient with lumbar discogenic pain undergoes transforaminal epidural injections at L2-L3 and L3-L4 levels, with fluoroscopic guidance.
  10. A patient with lumbar radiculopathy due to scar tissue formation from previous surgery receives transforaminal epidural injections at L5-S1 and S1-S2 levels, with CT guidance.

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