2025 CPT code 64479
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level.
Modifiers may be applicable depending on the circumstances of the procedure. Examples include modifier 50 for bilateral procedures (where applicable), 22 for increased procedural services, and 59 for distinct procedural services.Consult the appropriate payer guidelines for specific modifier rules.
The medical necessity for this procedure is established by the presence of radiculopathy or radiculitis causing significant pain and functional limitations unresponsive to conservative treatment options. The procedure should be considered medically necessary when non-invasive treatments (e.g., physical therapy, medication) have not provided adequate pain relief.
A physician specializing in pain management or anesthesiology typically performs this procedure. The clinical responsibility includes patient assessment, selecting appropriate anesthetic and steroid agents, performing the injection under imaging guidance, monitoring the patient's response, and providing post-procedure care instructions.
In simple words: This procedure involves injecting numbing medicine and/or steroid into the spine at one level in the neck or upper back to relieve pain from nerve irritation.Imaging technology like X-ray or CT scan guides the injection to ensure accurate placement.
This procedure involves the injection of an anesthetic agent and/or steroid into the transforaminal epidural space at a single cervical or thoracic level.Imaging guidance, such as fluoroscopy or CT, is used to precisely locate the target area.The injection is performed to alleviate pain and inflammation associated with nerve root compression or irritation. The procedure includes anesthesia of the skin and subcutaneous tissue, contrast injection to confirm needle placement (e.g., loss of resistance technique), and the administration of the anesthetic and/or steroid into the specified neuroforaminal epidural space.
Example 1: A patient presents with chronic neck pain radiating down the right arm (cervical radiculopathy).A transforaminal epidural injection at C5-C6 is performed using fluoroscopy guidance to deliver anesthetic and steroid to the affected nerve root., A patient experiences persistent low back pain with leg pain (lumbar radiculopathy). A transforaminal epidural injection is performed at the thoracic level (T5-T6) utilizing CT guidance to deliver medication to the inflamed nerve root., A patient has post-surgical pain after a thoracotomy. A transforaminal epidural injection at a single thoracic level is performed with fluoroscopic guidance to deliver local anesthetic and steroid to alleviate pain.
** Accurate coding requires precise documentation of the level(s) injected, the type and amount of medication used, and the use of imaging guidance.Any complications or adverse events should also be documented.
- Revenue Code: P6B
- Payment Status: Active
- Modifier TC rule: TC modifier is not applicable to this code because it is a complete procedure.
- Specialties:Anesthesiology, Pain Medicine, Neurology, Neurosurgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgery Center