Spinal Procedures

Spinal Procedures in PM&R

Tags: procedures spine injections

Overview

PM&R physicians commonly perform spinal interventions for pain management. Proper coding requires understanding anatomy levels and guidance requirements.

Epidural Steroid Injections (ESI)

Cervical/Thoracic

CPT	Description
64479	Injection, anesthetic/steroid, cervical/thoracic epidural
64480	With imaging guidance (fluoroscopy/CT)

Lumbar/Sacral

CPT	Description
64483	Injection, anesthetic/steroid, lumbar/sacral epidural
64484	With imaging guidance (fluoroscopy/CT)

Transforaminal Epidural Injections

CPT	Description
64483	Single level, lumbar/sacral
64484	Each additional level (add-on)
64489	Single level, cervical/thoracic
64490	Each additional level (add-on)

Facet Joint Injections

Medial Branch Blocks

CPT	Description
64490	Cervical/thoracic, single level
64491	Each additional level
64493	Lumbar/sacral, single level
64494	Each additional level

Radiofrequency Ablation (RFA)

CPT	Description
64633	Cervical/thoracic, single facet joint
64634	Each additional facet joint
64635	Lumbar/sacral, single facet joint
64636	Each additional facet joint

Documentation Requirements

Imaging Guidance

Fluoroscopy or CT guidance is required for most spinal injections. Document:

• Level(s) injected
• Contrast confirmation (if used)
• Images saved to permanent record
• Needle placement verified

Coding Tips

Level Counting

• Cervical: C1-C7
• Thoracic: T1-T12
• Lumbar: L1-L5
• Sacral: S1-S5

Add-On Codes

• Add-on codes (+) cannot be billed alone
• Must be billed with primary procedure code
• No modifier 51 on add-on codes

Same Day Limitations

• Maximum 4 levels typically allowed per session
• Multiple spinal regions same day may require modifier 59 or XS

Drug Billing

Steroids are billed separately with HCPCS J-codes:

• J3301: Triamcinolone acetonide (10mg)
• J1030: Methylprednisolone acetate (40mg)
• Use JW modifier for wasted amount

PM&R Coding MOC Injections & Blocks