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
Billing Guidelines
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.
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.
Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.
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.
CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.
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.
The epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of the infusion. 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.
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.
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).
** Preoperative evaluations for anesthesia are included in the fee for the administration of anesthesia and may not be billed as an E&M service.
** Regional IV anesthesia (e.g., 01995) is not based on time units; the base unit is covered. Therefore, only one unit of service may be billed. CPT 01995 is used only in situations involving the application of a tourniquet to a limb and injection of an agent for regional anesthesia.
** CPT surgical procedure codes (e.g., 62311 and 62319) are used for regional anesthesia. No base units or time units of anesthesia may be billed. Instead, one unit of service (an injection) is billed.
** Epidural for pain management other than the three stages of delivery (labor, delivery, and postpartum) must be billed with CPT 62311 and 62319. Time units may not be billed.
** CPT 01996 (Daily Management of Epidural or Subarachnoid Drug Administration) is not payable on the same day as the insertion of an epidural catheter or a general anesthesia service. The service unit for this procedure is one base unit.
** Epidural anesthesia for surgical procedures must be billed with the appropriate **0** anesthesia code with time units.
** Medications for pain relief given during the time of the epidural anesthesia are inclusive and must not be billed as a separate procedure.
** Local anesthesia and IV (conscious) sedation are bundled into the procedure being provided and must not be billed as separate services.
** Anesthesia services rendered during a hysterectomy or sterilization require completion, submission, and acceptance of the appropriate acknowledge/consent forms.
** Occasionally a procedure which is usually requires no anesthesia or local anesthesia, because of unusual circumstances, must be rendered under general anesthesia. A written description of the reason for using modifier 23 is required, and the claim will be sent for review.
WV Medicaid‘s payment policy for labor epidural is as follows:
** Labor epidural provided by the surgeon must be billed with the appropriate delivery anesthesia code and modifier 97. Labor epidural provided by the anesthesiologist and/or CRNA must be billed with the appropriate **0** anesthesia code
** CPT surgical codes 62311 and 62319 are not to be used to bill pain management for the three stages of delivery.
** Medications for pain relief given during the time of the epidural anesthesia are not covered as a separate procedure.
** Only one provider or team will be paid for epidural services.
** Emergency anesthesia is not allowed with the provision of epidural anesthesia or vaginal deliveries.
** The labor epidural procedures covered by WV Medicaid are inclusive of labor, delivery, and postpartum care. Additional procedure codes used for pain management are not covered.
** Modifiers defining the CRNA or anesthesiologist participation are used in processing to allocate payments. (e.g., AD,QK,QX,QY, and QZ) The supervising/medical directing anesthesiologist/ CRNA must bill the same procedure code.
** Physical status modifiers are not used for processing by WV Medicaid. The billing of additional base units for physical status is prohibited.
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.
Indications
These procedures are used to inject a substance into the subarachnoid, subdural or epidural space for the relief of pain or spasticity. The following list of examples is not all inclusive of the indications for injections of the spinal canal.
Intervertebral disc disease (with neuritis, radiculitis, sciatica) with or without myelopathy;
Complex regional pain syndrome;
Post herpetic neuralgia;
Traumatic neuropathy of the spinal nerve roots;
Postlaminectomy syndrome (failed back syndrome);
Chronic severe pain due to carcinoma;
Acute and chronic postoperative pain;
Chronic upper and lower extremity radicular symptoms (i.e. spinal stenosis).
Prior to any interventional pain procedure and regardless of the longevity of pain (i.e. acute, subacute, chronic, etc.), a patient must have failed to respond to conservative management. Examples of conservative management include physical therapy modalities, chiropractic manipulation, and medication management. The fact that a patient has chronic pain does not preclude the option of a retrial of conservative management at some point during their care. Although conservative management should be attempted, this requirement may be waived for the infrequent patient who is unable to tolerate it.
Limitations
An injection session is defined as all injection services of the spinal canal administered during a 24 hour period for a specific date of service per region (cervical, thoracic or lumbosacral). Therefore,
In the first year, up to six (6) injection sessions per region may be performed: up to two (2) diagnostic and up to four (4) therapeutic.
In the following years, up to four (4) therapeutic injection sessions per region may be performed.
There is limited peer-reviewed medical literature substantiating the use of alcohol, phenol, or iced saline solutions for either subarachnoid or epidural pain relief (CPT codes 62280, 62281, 62282). Use of these codes requires specific narrative documentation supporting the use of either alcohol, phenol, or iced saline solutions.
The use of fluoroscopic or computed tomographic (CT) guidance is required when performing injections of the spinal canal. Transforaminal epidural injections with ultrasound guidance (CPT codes 0228T – 0231T) will be denied as investigational.
Performance of more than one type of injection for pain treatment, such as epidural, sacroiliac joint injections or lumbar sympathetic injections, on the same day as a diagnostic spinal injection is not considered reasonable and necessary.
Clinicians performing these services must have appropriate training in interventional pain management and radiographic guidance. Documentation of this training must be maintained at the site of practice.
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
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.