Question: How should I code for a dorsal root ganglion injection? The doctor says that it's not a trigger point injection, and I don't know how else to code it.
South Carolina Subscriber
Answer: There really is not a good code for a dorsal root ganglion, which means coders are apt to report it different ways. The dorsal root is very close to the tranforaminal area of the spine, so you could use transforaminal epidural codes. These include 64479 (Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level) and +64480 ( cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) or 64483 ( lumbar or sacral, single level) and +64484 ( lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).
Another option is to code according to the injection location with 64505* (Injection, anesthetic agent; sphenopalatine ganglion) or 64510* ( stellate ganglion [cervical sympathetic]). If the injection location is not noted on the report, use 64450* (Injection, anesthetic agent; other peripheral nerve or branch).
With any codes reported, append modifier -22 (Unusual procedural services) and include documentation explaining the procedure.