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Nancy Posted Tue 25th of January, 2011 17:30:16 PM

I have a provider who did a L4/5 lumbar translaminar epidural steroid injection with use of dye and interpretation of fluoroscopy for level translaminar injection. His procedure notes are as followed: The patient was taken to the injection suite in the office , lying in a prone position. The lumbar spine was draped and prepped in the normal sterile fashion. Biplanar fluoroscopy was used. We anesthetized the skin with 1% lidocaine at L4/5. A Tuohy needle was inserted in the transforaminal position. We aspirated and there was no blood or CSF. radiographic dye was then inserted and the appropriate pattern was seen. Next, 80mg of Depo-Medrol and 2cc of 0.5% marcaine was injected at each level.
CPT codes billed were:62311 & 77003. Dx 724.4. This is the first time one of my provider has billed CPT code 62311 and I am trying to understand if this is correct. Please help me. Thanks

SuperCoder Answered Tue 25th of January, 2011 22:34:23 PM

For 64483, the approach is transforaminal whereas in 62311 it is translaminar. As per the coding convention, unless otherwise specified the procedure is considered to be done via a trans laminar approach i.e: 62311. Only when specified as trans foraminal would we use 64483. In your case the report in the middle says needle was inserted in transforaminal position, but on the first line of the report you mentioned that the provider did a translaminar epidural steroid injection. If it is translaminar, then truly it would be 62311 with 77003 (fluroscopy)

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