How To Use CPT Code 62321

CPT 62321 involves the injection of diagnostic or therapeutic substances into the cervical or thoracic region under imaging guidance. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 62321 procedures.

1. What is CPT 62321?

CPT 62321 is a medical procedure code used to describe the injection of diagnostic or therapeutic substances, such as anesthetic, antispasmodic, opioid, steroid, or other solutions, into the interlaminar epidural or subarachnoid space of the cervical or thoracic region under imaging guidance, like fluoroscopy or CT. This code is used by medical coders and billers to accurately document and bill for this specific procedure.

2. 62321 CPT code description

The official description of CPT code 62321 is: “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)”.

3. Procedure

1. The patient is appropriately prepped, and the area is anesthetized.
2. The provider advances a needle into the skin, toward the interlaminar epidural or subarachnoid space in the cervical or thoracic region, under fluoroscopy or CT guidance.
3. A small amount of contrast material (dye) may be injected to confirm the location of the needle, taking care to avoid any injury to the nearby nerve roots and spinal cord.
4. The provider injects a substance, such as an epidural steroid solution, for either diagnostic or therapeutic purposes.
5. The patient is monitored for 15 to 20 minutes after the injection.
6. After the procedure, the provider extracts the needle, flushes the site with sterile saline, and applies gauze over the site of needle insertion.

4. Qualifying circumstances

Patients eligible to receive CPT 62321 services are those experiencing pain, inflammation, or other symptoms related to the cervical or thoracic region that require diagnostic or therapeutic intervention. This procedure may be used to diagnose the source of pain or to provide relief from pain and inflammation caused by conditions such as spinal stenosis, herniated discs, or degenerative disc disease. The provider must determine that the patient’s condition warrants the use of this procedure and that the patient is an appropriate candidate for the injection.

5. When to use CPT code 62321

It is appropriate to bill the 62321 CPT code when the provider performs an injection of diagnostic or therapeutic substances into the cervical or thoracic region under imaging guidance. This code should be used when the procedure includes needle or catheter placement, interlaminar epidural or subarachnoid injection, and the use of fluoroscopy or CT for guidance. If the provider performs this procedure without imaging guidance, report CPT 62320 instead.

6. Documentation requirements

To support a claim for CPT 62321, the provider must document the following information in the patient’s medical record:

• Indication for the procedure, including the patient’s symptoms and diagnosis
• Details of the procedure, including the type of substance injected, the location of the injection, and the use of imaging guidance
• Any complications or adverse reactions experienced by the patient during or after the procedure
• Outcome of the procedure, including any improvement in the patient’s symptoms or condition

7. Billing guidelines

When billing for CPT code 62321, it is essential to follow the appropriate guidelines and rules to ensure accurate reimbursement. Do not report CPT 62321 in conjunction with 77003, 77012, or 76942, as these codes are considered bundled and should not be billed separately. If the provider performs the injection in the lower back or tailbone area, report CPT 62323 instead.

8. Historical information

CPT 62321 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to the code since its addition.

9. Similar codes to CPT 62321

Five similar codes to CPT 62321 and how they differentiate are:

1. CPT 62320: This code is used for the same procedure as CPT 62321 but without imaging guidance.
2. CPT 62322: This code is for the injection of diagnostic or therapeutic substances into the lumbar or sacral region without imaging guidance.
3. CPT 62323: This code is for the injection of diagnostic or therapeutic substances into the lumbar or sacral region with imaging guidance.
4. CPT 62324: This code is for the continuous infusion or intermittent bolus of diagnostic or therapeutic substances into the cervical or thoracic region without imaging guidance.
5. CPT 62325: This code is for the continuous infusion or intermittent bolus of diagnostic or therapeutic substances into the cervical or thoracic region with imaging guidance.

10. Examples

Here are 10 detailed examples of CPT code 62321 procedures:

1. A patient with cervical spinal stenosis receives an epidural steroid injection under fluoroscopic guidance to alleviate pain and inflammation.
2. A patient with a herniated thoracic disc undergoes a diagnostic injection of anesthetic under CT guidance to determine the source of pain.
3. A patient with degenerative disc disease in the cervical region receives a therapeutic injection of a steroid solution under fluoroscopic guidance to reduce inflammation and improve mobility.
4. A patient with chronic neck pain undergoes a diagnostic injection of an opioid under CT guidance to identify the cause of their symptoms.
5. A patient with thoracic radiculopathy receives an epidural steroid injection under fluoroscopic guidance to alleviate pain and inflammation.
6. A patient with cervical spondylosis undergoes a diagnostic injection of an antispasmodic under CT guidance to determine the source of pain and muscle spasms.
7. A patient with a thoracic disc protrusion receives a therapeutic injection of a steroid solution under fluoroscopic guidance to reduce inflammation and improve mobility.
8. A patient with chronic upper back pain undergoes a diagnostic injection of an opioid under CT guidance to identify the cause of their symptoms.
9. A patient with cervical foraminal stenosis receives an epidural steroid injection under fluoroscopic guidance to alleviate pain and inflammation.
10. A patient with thoracic facet joint syndrome undergoes a diagnostic injection of an anesthetic under CT guidance to determine the source of pain.