2025 CPT code 64484
(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), lumbar or sacral, each additional level.
Modifier 50 (bilateral procedure) may be applied to 64483 but not to 64484.Other modifiers may be necessary depending on the specific circumstances (e.g., 59, for distinctly separate procedures).
Medical necessity is established through documentation of symptoms consistent with nerve root compression or inflammation, such as radiculopathy or lower back pain, which did not respond to conservative treatment.Imaging findings may support the diagnosis, such as MRI or CT findings of disc herniation, spinal stenosis, or facet joint syndrome.
The physician identifies the target nerve root under imaging guidance, performs the injection, and manages any potential complications.
In simple words: This code covers additional injections into the lower back after the first injection for pain relief.A doctor uses imaging (like X-ray or CT scan) to guide the injection of numbing medicine and/or steroid into the spine to treat lower back pain or leg pain.
This CPT code describes the injection of an anesthetic agent and/or steroid into the lumbar or sacral spine via a transforaminal epidural approach, using imaging guidance (fluoroscopy or CT). This code is reported for each additional level injected after the initial level, and should be listed separately in addition to the code for the primary procedure (64483). Imaging guidance and any contrast injection are inclusive components of this code and are not reported separately.The procedure involves identifying the lumbar or sacral vertebrae and its corresponding nerve root under imaging guidance.Local anesthesia is administered, followed by contrast injection to visualize the needle tip location. Finally, the anesthetic and/or steroid is injected into the targeted nerve root's neuroforaminal epidural space.This is an add-on code and requires a primary procedure code for reimbursement.
Example 1: A patient presents with chronic lower back pain radiating down their right leg (sciatica) due to a herniated disc at L4-L5.After performing a single-level transforaminal epidural injection at L4-L5 (64483), the physician identifies additional nerve root irritation at L5-S1.Code 64484 is added to the claim to represent the additional injection at L5-S1., A patient with degenerative disc disease experiences pain across multiple lumbar levels. The physician decides to perform a multi-level transforaminal injection using imaging guidance. A single-level injection at L3-L4 is performed (64483) followed by additional injections at L4-L5 and L5-S1, each billed with 64484. This approach requires appropriate documentation detailing the need for each level's injection., A patient presents with severe low back pain radiating into the bilateral legs.After a thorough examination, a physician decides to perform a bilateral transforaminal epidural injection at the L4-L5 level.The physician performs a single level injection on the right side (64483 with modifier 50) followed by another single level injection on the left side (64483 with modifier 50).Then the physician performs a second level injection at L5-S1 on the right and left side (64484 reported twice).
Comprehensive documentation is required, including the medical necessity for the procedure, the specific levels injected, imaging reports demonstrating the needle placement, types and amounts of medication administered, and any complications.
** Payers may have specific requirements for medical necessity and documentation. Always refer to the payer's specific guidelines.
- Revenue Code: P6B
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Anesthesiology, Pain Management, Neurosurgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department