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...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses selected coding questions in the nervous system surgery section of CPT Assistant. It discusses how to approach reporting for certain spine and injection procedures when imaging is or is not used, along with the use of unlisted procedure reporting and supporting documentation. It is most relevant to professional coders, billing staff, and clinicians working with pain management, spine, and musculoskeletal injection services.

Why This Topic Matters

The piece helps readers understand the scope of guidance discussed in a CPT Assistant Q&A and whether it relates to spinal injections, trigger point injections, facet-related aspiration, and documentation for unlisted procedures.

Article Sections

  1. July 2011 page 16b

    Introduces the issue date and page reference for the Q&A content in the nervous system surgery section.

What You Will Learn

  • The general coding topics addressed in this Q&A article
  • How unlisted procedure reporting is discussed for certain nervous system procedures
  • What documentation considerations are mentioned for services reported with unlisted codes
  • Which broad procedure categories are covered in the article

Who Should Read This

  • Professional coders
  • Billing staff
  • Compliance staff
  • Physicians and procedure documentation staff
  • Pain management and spine practice teams

Codes Discussed

Code Ranges Discussed


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