Transforaminal Epidural Injection

Transforaminal Epidural Injection

March 28, 2019

If I perform a transforaminal epidural injection of L4-L5 on both sides can I report CPT 64483 twice?  Also, when I use fluoroscopic guidance can I report that separately?

If you perform a bilateral transforaminal epidural injection (64483) you can report CPT 64483 with Modifier 50 (bilateral procedure).  Some payors require CPT 64483-single level (1 side) and 64483-50 (the other side) whereas some payors may require RT/LT.  It is important to check with your payor regarding reporting requirements.  Fluoroscopic guidance is included in the descriptor of CPT 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level) and cannot be submitted for separate payment.

*This response is based on the best information available as of 3/28/19.

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