How To Use CPT Code 64480

CPT 64480 describes the injection of an anesthetic agent and/or steroid in the form of a transforaminal epidural injection in the cervical or thoracic region. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 64480?

CPT 64480 can be used to describe the injection of an anesthetic agent and/or steroid in the form of a transforaminal epidural injection in the cervical or thoracic region. This code applies to each additional level after the initial level.

2. Official Description

The official description of CPT code 64480 is: ‘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).’ Notes: (Use 64480 in conjunction with 64479) (For transforaminal epidural injection at the T12-L1 level, use 64479).

3. Procedure

1. The provider identifies the cervical or thoracic vertebrae and its nerve root under the guidance of a fluoroscope or using computed tomography (CT) guidance.
2. The skin and subcutaneous tissue are anesthetized.
3. A contrast material is injected to identify the area of the joint in relation to the needle tip.
4. The provider administers an anesthetic and/or steroid 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

CPT 64480 is commonly performed in cases of radiculopathy or radiculitis in the cervical or thoracic region. It is used when an anesthetic agent and/or steroid is injected into the neuroforaminal epidural space to provide relief for the patient. This code applies to each additional level after the initial level.

5. When to use CPT code 64480

CPT code 64480 should be used when an anesthetic agent and/or steroid is injected into the neuroforaminal epidural space in the cervical or thoracic region. It is important to note that this code is an add-on code and should be reported with an appropriate primary code for reimbursement.

6. Documentation requirements

To support a claim for CPT 64480, the provider must document the following information:

• Identification of the cervical or thoracic vertebrae and its nerve root
• Anesthesia of the skin and subcutaneous tissue
• Injection of contrast material to identify the area of the joint
• Administration of an anesthetic and/or steroid into the neuroforaminal epidural space
• Indication that the injection is for an additional level following injection at the initial level

7. Billing guidelines

When billing for CPT 64480, ensure that the procedure is performed in the cervical or thoracic region and that imaging guidance (fluoroscopy or CT) is used. This code should be listed separately in addition to the code for the primary procedure. It is important to report CPT 64480 with an appropriate primary code for reimbursement.

8. Historical information

CPT 64480 was added to the Current Procedural Terminology system on January 1, 2000. There have been historical changes to the code, including updates to the description and the addition of notes.

9. Examples

1. A patient with radiculopathy in the cervical region receives a transforaminal epidural injection of an anesthetic agent and steroid at the C5-C6 level.
2. A patient with radiculitis in the thoracic region undergoes a transforaminal epidural injection of an anesthetic agent and steroid at the T8-T9 level.
3. Following an initial transforaminal epidural injection at the C7-T1 level, a patient with radiculopathy in the cervical region receives an additional injection at the C6-C7 level.
4. A patient with radiculitis in the thoracic region receives a transforaminal epidural injection of an anesthetic agent and steroid at the T10-T11 level.
5. After an initial transforaminal epidural injection at the T2-T3 level, a patient with radiculopathy in the thoracic region undergoes an additional injection at the T3-T4 level.
6. A patient with radiculitis in the cervical region receives a transforaminal epidural injection of an anesthetic agent and steroid at the C4-C5 level.
7. Following an initial transforaminal epidural injection at the T5-T6 level, a patient with radiculopathy in the thoracic region receives an additional injection at the T6-T7 level.
8. A patient with radiculitis in the cervical region undergoes a transforaminal epidural injection of an anesthetic agent and steroid at the C3-C4 level.
9. After an initial transforaminal epidural injection at the T11-T12 level, a patient with radiculopathy in the thoracic region receives an additional injection at the T12-L1 level using CPT code 64479.
10. A patient with radiculitis in the cervical region receives a transforaminal epidural injection of an anesthetic agent and steroid at the C2-C3 level.