2025 CPT code 62321
(Active) Effective Date: N/A Revision Date: N/A Surgery - Injection, Drainage, or Aspiration Procedures Surgical Procedures on the Spine and Spinal Cord Feed
Injection of diagnostic or therapeutic substances (e.g., anesthetic, antispasmodic, opioid, steroid) into the cervical or thoracic interlaminar epidural or subarachnoid space, with imaging guidance (fluoroscopy or CT).
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 59 for a distinct procedural service, 25 if performed with another significant service).Consult the CPT manual and local payer guidelines for specific modifier rules.
Medical necessity is established through documentation of failed conservative treatment, presence of significant pain and functional impairment caused by a spinal condition affecting the cervical or thoracic spine, and demonstration of appropriate clinical findings justifying the need for this intervention. The clinical documentation must support the diagnostic and therapeutic goals of the procedure.
The physician is responsible for proper patient preparation, including anesthesia.The physician then performs the injection under fluoroscopic or CT guidance, ensuring precise needle or catheter placement to avoid nerve root or spinal cord damage.Post-procedure monitoring for a short period is also included.The physician documents the procedure, including the type and amount of substance injected, the location of the injection, and any complications.
In simple words: This code describes an injection of medicine (like pain relief or steroid medication) near the spinal nerves in the neck or upper/middle back. The doctor uses imaging (like an X-ray or CT scan) to guide the needle or tube into the right spot and to make sure the medication is given correctly.It includes all parts of the procedure, including the imaging.
This CPT code encompasses the injection of diagnostic or therapeutic substances, excluding neurolytic agents, into the interlaminar epidural or subarachnoid space of the cervical or thoracic spine.The procedure includes needle or catheter placement and utilizes imaging guidance, specifically fluoroscopy or computed tomography (CT), for precise localization. The injected substances may include anesthetics, antispasmodics, opioids, steroids, or other solutions.Contrast material may be used for confirmation of needle placement.The code is reported only once even if multiple injections are performed on the same day at multiple levels within the same spinal region.If the injection spreads to another spinal region (e.g., from cervical to thoracic), only one code is reported. Fluoroscopic guidance and contrast injection are inclusive components of this code; separate imaging codes should not be added.
Example 1: A patient presents with chronic neck pain radiating into the right arm (cervical radiculopathy).The physician performs an interlaminar epidural injection at C5-C6 with a steroid and local anesthetic under fluoroscopic guidance. Code 62321 is reported., A patient experiences severe mid-back pain (thoracic pain) stemming from a herniated disc at T6-T7. The physician performs an interlaminar epidural injection at this level, guided by CT, using a steroid and local anesthetic. The physician documents the injection level and confirms the position of the needle tip using contrast dye. Code 62321 is used., A patient with severe upper back pain has undergone a failed back surgery syndrome. The patient reports worsening thoracic pain with an associated increase in disability and reduced functionality. The pain management physician performs a fluoroscopically guided diagnostic interlaminar epidural injection at the T4-T5 level using local anesthetic and contrast media.Code 62321 is reported.
* Detailed history and physical examination documenting the indication for the procedure.* Imaging studies (fluoroscopy or CT) showing needle/catheter placement.* Procedure note describing the technique, location of the injection(s), type and amount of substance(s) injected, and any complications.* Anesthesia records if anesthesia is used.* Post-procedure assessment and monitoring notes.
** This procedure might involve the use of a catheter if multiple injections are anticipated over a longer period. If so, different codes (62324-62327) may be applicable. The choice of code depends on the specific location of the injection and the use of a catheter. Always refer to the most recent CPT manual for the most current coding guidelines.
- Payment Status: Active
- Modifier TC rule: Not applicable
- Specialties:Anesthesiology, Pain Management, Neurosurgery, Orthopedic Surgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center