What is the correct CPT (Current Procedural Terminology) code for a transforaminal epidural injection procedure, where a spinal needle is inserted using a transforaminal approach, causing paresthesia in the left lower extremities, and anesthetic drug is injected into the epidural space for a patient with multilevel lumbar degenerative disc disease?

CPT Coding for Transforaminal Epidural Injection

The correct CPT code for a transforaminal epidural injection at the L5-S1 level is 64483, which represents "Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance; lumbar or sacral, single level."

Understanding Transforaminal Epidural Injections and Coding

Transforaminal epidural injections are specialized procedures used to deliver medication directly into the epidural space via the neural foramen. This approach is particularly beneficial for patients with lumbar degenerative disc disease causing radicular symptoms, as in this case.

Key Elements for Proper Coding:

1. Approach Type: The case specifically mentions a TRANSFORAMINAL approach, which is a critical determinant of the CPT code

   • Transforaminal approach (through the neural foramen): 64483 for single level
   • This differs from interlaminar approaches (64483 vs 62323)

2. Anatomical Location: L5-S1 level (lumbar/sacral region)

   • Lumbar/sacral injections are coded differently than cervical/thoracic

3. Number of Levels: Single level (L5-S1) is specified

   • Additional levels would require add-on codes

4. Imaging Guidance: While not explicitly stated, transforaminal injections require imaging guidance per standard of care 1

Code Analysis

• 64483: Correct code - Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance; lumbar or sacral, single level
• 64484: Add-on code for each additional level (not applicable in this case)
• 64493: Incorrect - This code is for facet joint injections, not transforaminal epidural injections
• 64494: Incorrect - This is an add-on code for additional facet joint levels

Clinical Context

The patient presented with:

• 37-year-old with multilevel lumbar degenerative disc disease
• Procedure focused on L5-S1 level
• Transforaminal approach used
• Patient experienced paresthesia in left lower extremities (a common occurrence during needle placement near nerve roots)
• Anesthetic drug injected into epidural space

The transforaminal approach is particularly appropriate for this patient as it allows targeted delivery of medication to the specific nerve root that may be affected by the degenerative disc disease 1. The occurrence of paresthesia during the procedure is a common finding when the needle is positioned near nerve roots, which is expected in a transforaminal approach.

Common Coding Pitfalls to Avoid

1. Confusing approaches: Don't mistake transforaminal (64483) for interlaminar (62323) approaches
2. Incorrect level coding: Lumbar/sacral (64483) vs cervical/thoracic (64479)
3. Missing additional levels: If multiple levels were injected, add-on codes would be needed
4. Confusing with facet injections: Facet joint injections use the 64490-64495 series

In summary, based on the procedural details provided (transforaminal approach at L5-S1 level), the correct CPT code is 64483.