2025 CPT code 64480
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
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)
This code is not typically reported with modifiers other than anatomical modifiers (RT or LT) to specify the side of the body where the injection was performed, if applicable.
Medical necessity for this procedure must be established through documentation of the patient's symptoms, prior conservative treatments, and the expected benefit of the injection. The diagnosis should be consistent with a condition that could be relieved by a transforaminal epidural injection, such as radiculopathy, radiculitis, or spinal stenosis.
The physician performing this procedure is responsible for evaluating the patient's condition, determining the appropriate injection site and medication, administering the injection under imaging guidance, and managing any potential complications.
In simple words: This procedure involves injecting medication around the spinal nerves in the neck or upper back to relieve pain.The doctor uses a special x-ray or CT scan to guide the needle. This code is used for each additional level injected, after the first one.
This code describes the injection of an anesthetic agent and/or steroid into the transforaminal epidural space of the cervical or thoracic spine, using imaging guidance (fluoroscopy or CT). It is used for each additional level injected, after the initial level.The injection is performed to diagnose or treat pain conditions related to the spinal nerves. Imaging guidance ensures accurate placement of the needle and medication.
Example 1: A patient with cervical radiculopathy (pain radiating down the arm) caused by a herniated disc at two levels receives a transforaminal epidural injection at each level. 64479 would be reported for the first level and 64480 for the second level., A patient experiences thoracic back pain radiating around the chest due to nerve inflammation. Two levels are identified as the source of the pain, and the physician performs transforaminal epidural injections at both levels under fluoroscopic guidance.64479 would be reported for the first level, and 64480 would be reported for the second level., A patient presents with pain, numbness, and tingling in their right arm and hand consistent with cervical radiculopathy affecting C6 and C7 nerve roots. Diagnostic and therapeutic transforaminal epidural injections are performed at both levels under CT guidance. The provider reports 64479 for the first level injected and 64480 for the additional level injected.
Documentation should include the diagnosis, the specific level(s) injected, the type of anesthetic and/or steroid used, the use of imaging guidance (fluoroscopy or CT), and any complications encountered. Supporting documentation, such as imaging reports and prior treatment records, may also be necessary.
** This information is current as of December 1, 2024.Coding guidelines and reimbursement policies are subject to change, so it's essential to verify the latest information with payers and coding resources.While I strive for accuracy, clinical judgment should always be used in code selection.
- Specialties:Pain Management, Anesthesiology, Radiology, Orthopedic Surgery, Neurosurgery
- Place of Service:Ambulatory Surgical Center, Office, Outpatient Hospital