2025 CPT code 62304
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral.
Modifiers such as 22 (Increased Procedural Services), 52 (Reduced Services), 53 (Discontinued Procedure), and others may be applicable under specific circumstances. Modifier 51 (Multiple Procedures) may not be applicable and will depend on payer policies.
Medical necessity for 62304 is established when other imaging methods, such as MRI or CT, are contraindicated or have not provided sufficient information to diagnose a suspected condition affecting the spinal cord, nerve roots, or surrounding structures in the lumbosacral region. Supporting documentation should clearly demonstrate the patient's symptoms, failed conservative treatments, and the reason why a myelogram is the most appropriate imaging study.
The physician prepares the patient and injects contrast into the subarachnoid space within the lumbar spine. Using fluoroscopy, the physician guides the injection and monitors the spread of contrast. The physician observes and interprets the flow of contrast and captures images of the spinal cord, nerve roots, and related structures in the lumbosacral region. Finally, the physician documents the findings.
In simple words: A special X-ray of your lower back where dye is injected to help see the nerves and spinal cord better. The doctor then looks at the X-rays taken during the procedure.
This code represents a myelography procedure performed via lumbar injection, which includes radiological supervision and interpretation specifically for the lumbosacral region of the spine.It involves injecting a contrast agent into the subarachnoid space in the lumbar area and using imaging guidance, such as fluoroscopy, to visualize the spinal cord, nerve roots, and surrounding structures in the lumbosacral area. The radiologist then interprets the images obtained during the procedure.
Example 1: A patient with persistent lower back pain and leg numbness who is unable to undergo an MRI due to a pacemaker requires a myelogram to assess for potential nerve root compression or spinal stenosis in the lumbosacral region., A patient with a history of spinal surgery experiences recurrent pain. A lumbar myelogram is performed to evaluate for postoperative complications like scarring or nerve impingement in the lumbosacral spine., A patient presents with symptoms suggestive of a cerebrospinal fluid leak.A myelogram via lumbar injection is performed to confirm the leak and pinpoint its location in the lumbosacral area.
Documentation should include details of the lumbar injection site, contrast agent used, real-time fluoroscopic guidance used, areas imaged (lumbosacral), and the radiologist's interpretation of the myelogram findings. Any identified abnormalities, such as nerve root compression, spinal stenosis, or CSF leaks, should be clearly documented. Additionally, any relevant patient history, such as prior spinal surgeries or contraindications to MRI, should be noted.
- Specialties:Radiology, Neurosurgery, Pain Management, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, and other facilities where imaging and injection procedures can be performed.