tci Outpatient Facility Coding Alert - 2016 Issue 10

Reader Question: Remember To Mention Laterality with Radiculitis Pain Management Codes

Question: A patient complains of severe low back radiculitis. The provider injected a combination of anesthetic and steroid (triamcinolone and methylprednisolone), using a 3-1/2-inch spinal needle, in the left L3-L4 neuroforaminal epidural space, under fluoroscopic guidance. How do we report this? Utah Subscriber Answer: You may report this with 64483 (injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT; lumbar or sacral, single level], along with modifier LT [left side]). This procedure is the injection of an anesthetic agent or steroid as a transforaminal epidural into a single level (either lumbar or sacral). Note: For...

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