CPT CODE 62310, 62311 - Epidural injection

procedure code and description

62310 - 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; cervical or thoracic - Average fee amount $230 - 260

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) Average fee amount $230 - 260

62318 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

62319 - Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) - average fee payment - $150 - $180

Coverage Indications, Limitations, and/or Medical Necessity

    Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

    Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

    1. Management of pain caused by intervertebral disc disease with or without myelopathy.

    2. Management of pain caused by spinal stenosis.

    3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

    4. Management of intractable pain due to complex regional pain syndrome.

    5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

    6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

    7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

    8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

    9. Management of pain caused by radiculitis (inflammation of the nerve roots).

    Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

    Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.

CPT/HCPCS Codes
  
    For Single Injection

    62310 Inject spine cerv/thoracic
    62311 Inject spine lumbar/sacral

    For Transforaminal Epidural Injections
 
    64479 Inj foramen epidural c/t
    64480 Inj foramen epidural add-on
    64483 Inj foramen epidural l/s
    64484 Inj foramen epidural add-on

Coding Guidelines

1. The HCPCS/CPT code(s) may be subject to Correct Coding initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the current version CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

2. All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim.

3. An imaging guidance code is billed only once per session for CPT code 77003, fluoroscopy or CPT code 77012 for CT guidance. Physicians may only bill for the professional component when imaging is performed in a hospital or non-office facility. No claim should be submitted for the hard or digital film(s) maintained to document needle placement.

4. The CPT code 72275 (Epidurography, radiological supervision and interpretation) differs from CPT code 77003 in that it represents a formal recorded and reported contrast study that includes fluoroscopy. Epidurography should only be reported when it is reasonable and medicallynecessary to perform a diagnostic study. Epidurography should not be billed when the contrast injection is part of the fluoroscopic guidance and contrast injection to confirm correct needle placement that is integral to the epidural, transforaminal and intrathecal injections addressed in the policy.

5. All the CPT codes applicable to this policy include allowance for the insertion of the needle into the epidural space, as well as the injection of the drug.

6. Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region.


7. The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

8. The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

9. Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.

10.Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

11. CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

12. These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier -59 should be used when billing these services to indicate that the catheter or injection was a separate procedure from the surgical anesthesia care.

13. The epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of theinfusion. Therefore, the daily management of epidural or subarachnoid drug administration (CPT code 01996) should not be billed for the same day as the catheter insertion.

14. The daily management of epidural or subarachnoid drug administration (CPT code 01996), is a daily service and should only be coded with a number of services (NOS) of one (1) for each day billed. Post-operative pain management services should be reported in the inpatient hospital setting (21) only.

15. When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one (1).

Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region

The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

When performed primarily for postoperative pain management the time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one

Old description and New description

62310 Inject spine c/t             Inject spine cerv/thoracic 
62311 Inject spine l/s (cd)          Inject spine lumbar/sacral


Bundling Issues with ESI Procedures

The 64479 code is Unbundled in the CCI Edits from code 62310 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Code 64483 is Unbundled from code 62311 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Therefore, for Medicare and other payors who observe the CCI edits, these codes are not billable together when they are performed at the SAME spinal area. If the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L4-5, the procedures are Unbundled and not both billable – only code 62311 would be billable in that case. However, if the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L3-4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the 2nd code following the 62311 ESI code on the claim form.


ICD-10 Codes that Support Medical Necessity
   
    For procedures codes: 62310, 62311, 64479, 64480, 64483 and 64484

    A52.15 Late syphilitic neuropathy
    B02.0 Zoster encephalitis
    B02.23 Postherpetic polyneuropathy
    B02.24 Postherpetic myelitis
    B02.29 Other postherpetic nervous system involvement
    C30.0 Malignant neoplasm of nasal cavity
    C30.1 Malignant neoplasm of middle ear
    C31.0 Malignant neoplasm of maxillary sinus
    C31.1 Malignant neoplasm of ethmoidal sinus
    C31.2 Malignant neoplasm of frontal sinus
    C31.3 Malignant neoplasm of sphenoid sinus
    C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
    C31.9 Malignant neoplasm of accessory sinus, unspecified
    C32.0 Malignant neoplasm of glottis
    C32.1 Malignant neoplasm of supraglottis
    C32.2 Malignant neoplasm of subglottis
    C32.3 Malignant neoplasm of laryngeal cartilage
    C32.8 Malignant neoplasm of overlapping sites of larynx
    C32.9 Malignant neoplasm of larynx, unspecified
    C33 Malignant neoplasm of trachea
    C34.00 Malignant neoplasm of unspecified main bronchus
    C34.01 Malignant neoplasm of right main bronchus
    C34.02 Malignant neoplasm of left main bronchus
    C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
    C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2 Malignant neoplasm of middle lobe, bronchus or lung
    C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
    C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
    C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
    C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
    C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
    C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
    C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
    C37 Malignant neoplasm of thymus
    C38.0 Malignant neoplasm of heart
    C38.1 Malignant neoplasm of anterior mediastinum
    C38.2 Malignant neoplasm of posterior mediastinum
    C38.3 Malignant neoplasm of mediastinum, part unspecified
    C38.4 Malignant neoplasm of pleura
    C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
    C39.0 Malignant neoplasm of upper respiratory tract, part unspecified
    C39.9 Malignant neoplasm of lower respiratory tract, part unspecified
    C40.00 Malignant neoplasm of scapula and long bones of unspecified upper limb
    C40.01 Malignant neoplasm of scapula and long bones of right upper limb
    C40.02 Malignant neoplasm of scapula and long bones of left upper limb
    C40.10 Malignant neoplasm of short bones of unspecified upper limb
    C40.11 Malignant neoplasm of short bones of right upper limb
    C40.12 Malignant neoplasm of short bones of left upper limb
    C40.20 Malignant neoplasm of long bones of unspecified lower limb
    C40.21 Malignant neoplasm of long bones of right lower limb
    C40.22 Malignant neoplasm of long bones of left lower limb
    C40.30 Malignant neoplasm of short bones of unspecified lower limb
    C40.31 Malignant neoplasm of short bones of right lower limb
    C40.32 Malignant neoplasm of short bones of left lower limb
    C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb
    C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
    C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
    C40.90 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb
    C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb
    C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb
    C41.0 Malignant neoplasm of bones of skull and face
    C41.1 Malignant neoplasm of mandible
    C41.2 Malignant neoplasm of vertebral column
    C41.3 Malignant neoplasm of ribs, sternum and clavicle
    C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
    C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
    C43.0 Malignant melanoma of lip
    C43.10 Malignant melanoma of unspecified eyelid, including canthus
    C43.11 Malignant melanoma of right eyelid, including canthus
    C43.12 Malignant melanoma of left eyelid, including canthus
    C43.20 Malignant melanoma of unspecified ear and external auricular canal
    C43.21 Malignant melanoma of right ear and external auricular canal
    C43.22 Malignant melanoma of left ear and external auricular canal
    C43.30 Malignant melanoma of unspecified part of face
    C43.31 Malignant melanoma of nose
    C43.39 Malignant melanoma of other parts of face
    C43.4 Malignant melanoma of scalp and neck
    C43.51 Malignant melanoma of anal skin
    C43.52 Malignant melanoma of skin of breast
    C43.59 Malignant melanoma of other part of trunk
    C43.60 Malignant melanoma of unspecified upper limb, including shoulder
    C43.61 Malignant melanoma of right upper limb, including shoulder
    C43.62 Malignant melanoma of left upper limb, including shoulder
    C43.70 Malignant melanoma of unspecified lower limb, including hip
    C43.71 Malignant melanoma of right lower limb, including hip
    C43.72 Malignant melanoma of left lower limb, including hip
    C43.8 Malignant melanoma of overlapping sites of skin
    C43.9 Malignant melanoma of skin, unspecified
    C44.00 Unspecified malignant neoplasm of skin of lip
    C44.01 Basal cell carcinoma of skin of lip
    C44.02 Squamous cell carcinoma of skin of lip
    C44.09 Other specified malignant neoplasm of skin of lip
    C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus
    C44.102 Unspecified malignant neoplasm of skin of right eyelid, including canthus
    C44.109 Unspecified malignant neoplasm of skin of left eyelid, including canthus


Documentation Requirements

Medical necessity for providing the service must be clearly documented in the patient’s medical record and submitted upon request for review.
Assessment of the outcome of this procedure depends on the patient’s responses, therefore documentation should include:

    Whether the block was a diagnostic or therapeutic injection
    Pre and post procedure evaluation of patient
    Patient education
    Subjective and objective response from the patient regarding pain provocative maneuvers documented by pre and post procedure measurement


According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, a positive response to a series of three (3) epidural injections, is noted when > 50 % relief is obtained for 6 to 8 weeks.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It is expected that providing an epidural block in conjunction with multiple facet joint blocks, bilateral sacroiliac joint injections, trigger point injections, and/or lumbar sympathetic blocks in any combination to a patient on the same day is not considered medically necessary, unless the patient has recently discontinued anticoagulant therapy for the purpose of interventional pain management. It is expected that interlaminar, transforaminal or caudal epidural injections are not performed on the same date of service at the same level.

Procedures performed during the diagnostic phase should be limited to two (2) injections.

Once a structure is proven to be negative as a pain generator, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.

In the treatment or therapeutic phase, a series of three (3) injections may be given at a minimum interval of two (2) weeks to the suspect level. If a positive response (per ASIPP guidelines) is not obtained, then a repeat series of injections at that level is considered not medically necessary.

It is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. (A level is defined as the articulation between two vertebrae i.e., C4-5; or L2-3).

A series of three (3) epidural injections may be repeated at six (6) month intervals (assuming there was a positive response as defined by the ASIPP guidelines) to the first series of three (3) injections. Caution should be used to monitor the side effects of frequent steroid use.

Under unusual circumstances with a recurrent injury, carcinoma, or reflex sympathetic dystrophy, blocks may be repeated more frequently in the treatment phase after stabilization. Documentation must be present in the medical record to support the more frequent use of such therapy in this setting.


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