AMA CPT® Assistant - 2011 Issue 7 (July)

Surgery: Nervous System (Q&A) (July 2011)

July 2011 page 16b Surgery: Nervous System Question: For CPT 2011, either fluoroscopy or computed tomographic (CT) needle guidance is required to qualify for reporting the transforaminal epidural injection codes 64479-64484 or ultrasound needle guidance for reporting Category III codes 0228T-0231T. How would a transforaminal epidural injection be coded if the physician did not use any image guidance? Are the trigger point injection codes 20552 and 20553 reportable? Answer: A transforaminal epidural injection cannot be performed without image guidance, therefore, a specific code recommendation cannot be provided if the physician does not use image guidance yet states that the...

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