As a pain management medical coding company, we help pain management physicians flawlessly navigate code and guideline revisions, and report services in keeping with payer policies and federal and state regulations. Epidural injections and diagnostic nerve root blocks are common interventional diagnostic procedures performed by pain management physicians. In addition to applying the correct CPT codes, providers need to document medical necessity of these services to protect their practice from preventable denials and audit risks.

 Epidural Injection Procedures

Acute low back is a common problem affecting more than 80% of adults at some time in their life. The epidural steroid injection (ESI) involves injecting a corticosteroid via into the epidural space surrounding the spinal nerve root to relieve spinal pain. ESI provides temporary or lasting relief from spinal pain or inflammation. Injections may be also administered as part of diagnosing radicular pain and can also help to confirm the exact site of the pain. Epidural steroid injections may be administered with or without fluoroscopic guidance. Imaging guidance is used to guide correct placement of the needle.

 Medical Necessity: ESI is considered medically necessary for the treatment of cervical, thoracic or lumbar pain when patients do not respond to conservative treatments such as physical therapy, medications, spinal manipulation, and active exercise. ESI may be indicated when the pain has not responded to at least 4 weeks or 6 weeks (based on the payer’s criteria) of appropriate conservative management. For e.g., Blue Cross Blue Shield (BCBS) considers ESI performed with fluoroscopic guidance medically necessary for the treatment of back pain when the following three criteria are met:

Lumbar or cervical radiculopathy (sciatica) that is not responsive to at least 4 weeks of conservative management; and

  • Presence of persistent pain of at least moderate-severe intensity; and
  • Anticipated outcome is short-term relief of pain

Payers also have their own rules on coverage of continued epidural steroid therapeutic injections. While Moda Health covers a maximum of 4 therapeutic injections in a twelve month period if the medical necessity criteria are met. United Healthcare considers a maximum of 3 ESI (regardless of level, location, or side) in a year as medically necessary.

 2019 Epidural Steroid Injection CPT Codes

0228T – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

0229T – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

0230T – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level

0231T – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

62320 – Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

62321 – Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

62322 – Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

62323 – Injection(s),of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epiduralor subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

64479 – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

64480 – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

64483 – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

64484 – Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Diagnostic Selective Nerve Root Injections (SNRIs)

Diagnostic SNRIs are used to diagnose radicular pain in atypical presentations. According to a study published in the journal Phys Med Rehabil Clin N Am. in 2002, diagnostic SNRIs are indicated in the following situations:

  • For atypical extremity pain
  • When imaging studies and clinical presentation do not compare
  • When electromyography and MRI are not confirmative or are equivocal
  • For anomalous innervations, such as conjoint nerve roots or furcal nerves
  • For failed back surgery syndrome with atypical extremity pain; and
  • For transitional vertebrae

In patients who do not respond to conservative, less invasive treatment, diagnostic SNRI can help pinpoint the specific spinal nerve or nerve rootfrom which the pain is emanating. However, diagnostic SNRI cannot determine the cause of the spinal nerve pain, nor provide any prognostic information. Treatment and prognosis would depend on factors such as the etiology of the nerve root pain, cause of injury, underlying anatomy, duration of symptoms, comorbidities, patient desire, physician skill, etc.

 CPT codes for Diagnostic Nerve Blocks

0213T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

0214T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)

0215T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

0216T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level

0217T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)

0218T – Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

64490 – Intraarticular joint or medial branch block (MBB) – cervical or thoracic (single level)

64491 – Intraarticular joint or medial branch block – cervical or thoracic (2nd level); (List separately in addition to code for primary procedure)

64492 – Intraarticular joint or medial branch block – cervical or thoracic (3rd level); (List separately in addition to code for primary procedure)

64493 – Intraarticular joint or medial branch block – lumbar or sacral (single level)

64494 – Intraarticular joint or medial branch block – lumbar or sacral (2nd level)

64495 – Intraarticular joint or medial branch block – lumbar or sacral (3rd level)

Payers have specific coverage rules regarding what they consider medically necessary as well as riders and exclusions for diagnostic facet joint injections and medial branch blocks.

Pain management physicians face many reimbursement challenges. Experienced medical billing outsourcing companies have experts who can help them code and bill these procedures correctly and overcome the hurdles that that stand in the way of their claims and compliance success.