AMA Clinical Examples in Radiology - 2016 Issue 4 (Fall)
Radiology Test Case Answer: Epidural Steroid Injection
RADIOLOGY TEST CASE ANSWER Epidural Steroid Injection HOW TO CODE For dates of service before January 1, 2017 , procedure coding should be as follows: 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) 77003 luoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) G9500 Radiation exposure indices or exposure time and number of fluorographic images in final report for procedures...
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Article Overview
This radiology coding article explains how an epidural steroid injection case is handled under different date-of-service rules and reporting frameworks. It is aimed at coders, billing staff, and clinicians who need to understand the intersection of procedure coding, imaging guidance, diagnosis coding, quality reporting, and payer-specific policy differences. The discussion also summarizes related coding updates, including changes tied to CPT revisions, Medicare reporting, and a JW modifier policy update for discarded drugs.
Why This Topic Matters
The article helps readers distinguish which reporting approach applies based on the date of service and payer context. That matters because procedure, imaging, sedation, and quality-reporting requirements change over time and may differ for Medicare versus non-Medicare claims.
Article Sections
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How to Code
Addresses the case coding framework for the procedure, associated imaging, and related diagnosis reporting. Also distinguishes guidance by date of service and payer context.
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Discussion
Summarizes the coding rationale, references to CPT and PQRS guidance, and later CPT changes affecting spinal injection reporting. Also covers related notes on sedation, modifier use, and discarded-drug reporting policy.
What You Will Learn
- How the case is framed under pre- and post-2017 coding guidance
- Which broad code sets and reporting categories are involved in the discussion
- How imaging, sedation, and quality-reporting topics relate to the procedure
- What payer policy considerations are mentioned in the article
- Which coding updates and effective-date changes are addressed
Who Should Read This
- Medical coders
- Radiology billing staff
- Compliance professionals
- Physician documentation staff
- Clinicians involved in procedure documentation
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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