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Coding tip: Code epidural steroid injections by region of single injection

Ambulatory Surgery Reimbursement Update, July 31, 2007

Bill epidural steroid injections (ESIs) using CPT code 62310, which pertains to the cervical/thoracic regions of the body.

Use code 62311 for lumbar/sacral/caudal regions of single injections not performed via an indwelling catheter if the injection does not include neurolytic substances. These injections can consist of either a diagnostic or therapeutic substance(s) and include an anesthetic, antispasmodic, opioid, steroid, or other solution.

Physicians perform ESIs in the epidural space of the spine for patients who suffer from pain caused by disorders in the spine, such as disc herniations, post-laminectomy syndrome, or complex regional pain syndromes, which require nerve blockade in and around the spine.

Bill the epidural steroid injection once per level once per side regardless of the number of injections per level and side.

If you use fluoroscopy, bill code 77003 for the fluoroscopic guidance, paraspinous diagnostic or therapeutic injection procedures and localization of needle or catheter tip. Fluoroscopic guidance can only be billed once per region. If a physician performs injections in both the cervical and lumbar areas, you could bill the fluoroscopic code twice. Use modifier -59 on subsequent repeat listings of the same code billed more than once to help avoid a payer denial.

This tip is brought to you by Ellis Medical Consulting, Inc.