Health Information Management

Understand the spine to code back procedures correctly

HIM-HIPAA Insider, February 22, 2005

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Two problems that frequently surface when coding spinal procedures are inadequate physician documentation and lack of coder knowledge of the anatomy of the spine. Both can lead to a loss in reimbursement.

"It is important that you understand what a 'spinal level/segment' represents," says Tiffany Neally, RHIA, CCS, a remote coding operations manager for Precyse Solutions, LLC, in King of Prussia, PA. "And the physicians at your facility must be educated regarding documentation."

What is a spinal level/segment?
A spinal segment is composed of two vertebra, the intervertebral disc between them, and the two nerve roots that exit from that spinal level, one from each side. For example, L4-L5 would make up one spinal segment/level. Go to for more anatomical information.

CPT codes 64483 and 64484 describe injections into the spine. You may report them together or separately. The following is an example of appropriate use of these codes:

  • Diagnosis: Bilateral lower extremity pain due to spondylolisthesis
  • Procedure: Transforaminal epidural injections
  • Technique: Patient is prepped and draped. From an LPO projection, a 22-gauge spinal needle is advanced just inferior to the left of the L4-L5 and L5-S1 pedicles, as visualized fluoroscopically using standard technique and after administering local anesthesia. A small amount of contrast is injected to find an appropriate epidural location. A standard mixture of Marcaine and Depo-Medrol is injected at each level. The same procedure is performed on the right side. There aren't complications, and the patient is moved to the recovery room.
  • Coding: The patient had bilateral transforaminal epidural injections at two spinal segments. So to correctly code this procedure, use 64483-50 (injection, anesthetic agent/steroid, transforaminal epidural; lumbar or sacral single level-bilateral) and 64484-50 (injection, anesthetic agent/steroid, transforaminal epidural; each additional level-bilateral).

Coding guidelines
PT codes 64479-64484 have a bilateral surgery indicator of one. Thus, they are considered "unilateral" procedures, and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, append modifier -50. When injecting a nerve root unilaterally, append the appropriate anatomic modifier -LT or -RT.

Submit only one unit of service for a transforaminal epidural injection for a unilateral or bilateral injection at the same level. Indicate the nerve root(s) injected, (e.g., C3, L5, etc.) in the electronic notepad or in item 19 of the CMS-1500 form.

Whether a transforaminal epidural block is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

You also need to report CPT code 76005 for fluoroscopy and 76360 for computed tomography guidance. Bill an imaging guidance code only once per session. CPT code 77275 (epidurography, radiological supervision and interpretation) differs from CPT code 76005 in that it represents a formal recorded and reported contrast study that includes fluoroscopy.

"Only report epidurography when it is reasonable and medically necessary to perform a diagnostic study," says Neally. "It should not be billed for the usual work of fluoroscopy and dye injection that is integral to the transforaminal epidural injection(s)."

This excerpt is adapted from the newsletter Briefings on APCs.

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