How To Use CPT Code 64483

CPT 64483 describes the injection of an anesthetic agent and/or steroid into a single level of the lumbar or sacral area using a transforaminal epidural injection. 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 64483?

CPT 64483 is used to describe the injection of an anesthetic agent and/or steroid into a single level of the lumbar or sacral area using a transforaminal epidural injection. This procedure is commonly performed to alleviate lower back pain or radiculitis. The provider uses fluoroscopy or computed tomography (CT) guidance to identify the specific vertebrae and nerve root. The injection is administered into the neuroforaminal epidural space, targeting the nerve root.

2. Official Description

The official description of CPT code 64483 is: ‘Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level.’

3. Procedure

1. The provider identifies the lumbar or sacral vertebrae and its corresponding nerve root using fluoroscopy or CT guidance.
2. The skin and subcutaneous tissue are anesthetized.
3. A contrast material may be injected to visualize the area of the joint in relation to the needle tip.
4. The provider administers an anesthetic agent and/or steroid into the neuroforaminal epidural space, targeting the nerve root.

4. Qualifying circumstances

CPT 64483 is performed on patients experiencing lower back pain or radiculitis. The injection is targeted at a single level in the lumbar or sacral area. It is important to note that for bilateral procedures, a different set of codes should be used.

5. When to use CPT code 64483

CPT code 64483 should be used when a provider performs a transforaminal epidural injection with imaging guidance (fluoroscopy or CT) on a single level in the lumbar or sacral area. It is important to ensure that the injection is targeted at the specific nerve root causing the patient’s symptoms.

6. Documentation requirements

To support a claim for CPT 64483, the provider must document the following information:

• Patient’s diagnosis and indication for the injection
• Specific level of the lumbar or sacral area targeted
• Imaging guidance used (fluoroscopy or CT)
• Date and time of the procedure
• Type and amount of anesthetic agent and/or steroid administered
• Any complications or adverse reactions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 64483, ensure that the procedure meets the criteria specified in the code description. It is important to use the appropriate modifiers if the procedure is performed bilaterally or if imaging guidance is not used. Additionally, be aware of any bundling or unbundling issues with other related codes.

8. Historical information

CPT 64483 was added to the Current Procedural Terminology system on January 1, 2000. Since then, there have been a few updates to the code, including changes to the code description and the addition of modifiers.

9. Examples

1. A patient with chronic lower back pain receives a transforaminal epidural injection at the L4-L5 level to alleviate their symptoms.
2. An individual with radiculitis in the sacral area undergoes a transforaminal epidural injection at the S1 level for pain relief.
3. A provider administers an anesthetic agent and steroid into the lumbar neuroforaminal epidural space using fluoroscopy guidance to treat a patient with sciatica.
4. A patient with degenerative disc disease receives a transforaminal epidural injection at the L3-L4 level to manage their pain.
5. An individual with a herniated disc in the lumbar area undergoes a transforaminal epidural injection at the L5-S1 level to alleviate their symptoms.
6. A provider performs a transforaminal epidural injection at the S2 level for a patient with sacroiliac joint dysfunction.
7. A patient with lumbar spinal stenosis receives a transforaminal epidural injection at the L2-L3 level to relieve their symptoms.
8. An individual with postoperative pain in the lumbar area undergoes a transforaminal epidural injection at the L1 level for pain management.
9. A provider administers an anesthetic agent and steroid into the sacral neuroforaminal epidural space using CT guidance to treat a patient with coccydynia.
10. A patient with spondylolisthesis receives a transforaminal epidural injection at the L5 level to alleviate their symptoms.