In simple words: This procedure helps relieve lower back pain or sciatica by injecting medicine around a specific nerve in your lower back.A special x-ray or CT scan is used to make sure the medicine reaches the right spot.

This code describes a procedure where an anesthetic agent and/or steroid is injected into the transforaminal epidural space at a single level in either the lumbar or sacral region. Imaging guidance, using either fluoroscopy or CT, is an integral part of the procedure and is included in this code.The injection targets a specific nerve root.

Example 1: A patient with lumbar radiculopathy at L5 experiences severe leg pain. A transforaminal epidural injection at L5 is performed under fluoroscopic guidance to relieve the pain and inflammation., A patient with a herniated disc at S1 has persistent sciatica.A transforaminal epidural injection at S1 is performed with CT guidance to target the affected nerve root., A patient with lower back pain radiating to the leg undergoes a transforaminal epidural injection at the affected lumbar level using fluoroscopy to deliver medication directly to the source of the pain. Modifier -50 is applied as the procedure is bilateral.

Documentation should include the diagnosis, the specific level of injection (e.g., L4-L5), the type of imaging guidance used (fluoroscopy or CT), the medications injected, and the patient's response to the procedure. The medical necessity of the procedure must also be documented.

** Check with individual payers for specific coverage policies and documentation requirements. The average patient payment in 2024 for this code in an Ambulatory Surgical Center setting is about $115. This is just an average and the actual cost may vary.