How To Use CPT Code 64483

CPT 64483 refers to the procedure of injecting anesthetic agents and/or steroids via a transforaminal epidural injection at a single level in the lumbar or sacral region. This procedure is primarily utilized to alleviate pain associated with conditions such as lower back pain or radiculitis. The injection is performed under imaging guidance, either through fluoroscopy or computed tomography (CT), ensuring precise placement of the medication to target the affected nerve root.

1. What is CPT code 64483?

CPT code 64483 represents a specific medical procedure involving the injection of anesthetic and/or steroid medications into the transforaminal epidural space at a single level in the lumbar or sacral region of the spine. This procedure is particularly relevant in the management of pain conditions, especially those related to nerve root irritation or inflammation. The transforaminal approach allows for targeted delivery of medication directly to the affected nerve root, which can provide significant relief from pain and improve the patient’s functional abilities. The use of imaging guidance, such as fluoroscopy or CT, enhances the accuracy of the injection, minimizing the risk of complications and ensuring that the medication is delivered precisely where it is needed.

2. Qualifying Circumstances

This CPT code can be utilized in specific clinical circumstances where a patient presents with lower back pain or radiculitis that may benefit from targeted pain management. The procedure is appropriate when conservative treatments have failed, and there is a clear indication for a transforaminal epidural injection. Limitations include the necessity for imaging guidance to ensure proper placement of the needle and medication. It is important to note that this code is only applicable for a single level injection; if multiple levels require treatment, additional codes may be necessary. The use of this code is inappropriate in cases where the patient has contraindications to steroid use or when the pain is not related to nerve root involvement.

3. When To Use CPT 64483

CPT code 64483 is used when a healthcare provider performs a transforaminal epidural injection at a single lumbar or sacral level. This code should be employed when the procedure is performed under imaging guidance, ensuring that the injection is accurately placed. It is essential to document the clinical rationale for the procedure, including the patient’s history and previous treatments. This code cannot be used in conjunction with codes for multiple level injections or other procedures that involve the same anatomical area unless specified. Providers should also be aware of any payer-specific guidelines that may affect the use of this code.

4. Official Description of CPT 64483

Official Descriptor: Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level.

5. Clinical Application

The clinical application of CPT code 64483 is primarily in the treatment of lower back pain and radiculitis, conditions that can significantly impact a patient’s quality of life. The transforaminal epidural injection allows for direct delivery of medication to the affected nerve root, which can reduce inflammation and alleviate pain. This procedure is often considered when conservative treatments, such as physical therapy or oral medications, have not provided sufficient relief. The effectiveness of this intervention can lead to improved mobility and functionality for patients suffering from debilitating pain.

5.1 Provider Responsibilities

During the procedure, the provider first conducts a thorough assessment of the patient’s medical history and current symptoms. After obtaining informed consent, the provider prepares the patient and the necessary equipment. The area of injection is then sterilized, and local anesthesia may be administered to minimize discomfort. Using fluoroscopy or CT imaging, the provider carefully identifies the target lumbar or sacral vertebra and its corresponding nerve root. A contrast material is injected to confirm the correct placement of the needle. Once the appropriate position is verified, the provider injects the anesthetic and/or steroid medication into the neuroforaminal epidural space, ensuring that the medication is delivered precisely to the affected area.

5.2 Unique Challenges

One of the unique challenges associated with this procedure is the need for precise imaging guidance to ensure accurate needle placement. Variations in patient anatomy can complicate the procedure, requiring the provider to adapt their technique accordingly. Additionally, there is a risk of complications such as infection, bleeding, or nerve damage, which necessitates careful monitoring and adherence to safety protocols. The provider must also consider the patient’s overall health and any contraindications to steroid use, which can impact the decision to proceed with the injection.

5.3 Pre-Procedure Preparations

Before performing the transforaminal epidural injection, the provider must conduct a comprehensive evaluation of the patient’s condition. This includes reviewing imaging studies, such as MRI or CT scans, to assess the underlying cause of the pain. The provider should also evaluate the patient’s medical history for any contraindications to the procedure, such as allergies to anesthetic agents or steroids. Additionally, the provider may need to discuss the risks and benefits of the procedure with the patient and obtain informed consent.

5.4 Post-Procedure Considerations

After the injection, the patient is typically monitored for a short period to assess for any immediate adverse reactions. The provider may give instructions regarding activity restrictions and pain management following the procedure. Follow-up appointments may be scheduled to evaluate the effectiveness of the injection and determine if further treatment is necessary. It is essential for the provider to document the procedure details and any patient responses to ensure continuity of care.

6. Relevant Terminology

Transforaminal Epidural Injection: A procedure that involves injecting medication into the epidural space through the foramen, targeting specific nerve roots to alleviate pain.

Fluoroscopy: An imaging technique that uses X-rays to obtain real-time moving images of the interior of a body, often used to guide procedures.

Computed Tomography (CT): A diagnostic imaging technique that uses X-ray equipment and computer processing to create detailed cross-sectional images of the body.

Neuroforaminal Epidural Space: The space surrounding the nerve roots as they exit the spinal column, where injections can be administered to relieve nerve-related pain.

Contrast Material: A substance used in imaging procedures to enhance the visibility of structures within the body, aiding in accurate needle placement.

7. Clinical Examples

1. A patient with chronic lower back pain due to a herniated disc undergoes a transforaminal epidural injection to target the affected nerve root.

2. A patient experiencing radiculopathy following spinal surgery receives a steroid injection to reduce inflammation and alleviate pain.

3. A patient with sciatica related to lumbar spinal stenosis is treated with a transforaminal epidural injection to improve mobility.

4. A patient with persistent pain after conservative treatment for a lumbar strain is referred for a transforaminal epidural injection.

5. A patient with diabetic neuropathy receives a targeted injection to manage pain radiating down the leg.

6. A patient with a history of spinal fractures is evaluated for a transforaminal epidural injection to address ongoing pain.

7. A patient with failed back surgery syndrome is considered for a transforaminal epidural injection to provide symptomatic relief.

8. A patient with lumbar radiculitis is treated with a steroid injection to reduce nerve root inflammation.

9. A patient with acute lower back pain following an injury receives a transforaminal epidural injection as part of their pain management plan.

10. A patient with chronic pain from degenerative disc disease is evaluated for a transforaminal epidural injection to improve their quality of life.