March 28, 2019
If I perform a transforaminal epidural injection of L4-L5 on both sides can I report CPT 64483 twice? Also, when I use fluoroscopic guidance can I report that separately?
If you perform a bilateral transforaminal epidural injection (64483) you can report CPT 64483 with Modifier 50 (bilateral procedure). Some payors require CPT 64483-single level (1 side) and 64483-50 (the other side) whereas some payors may require RT/LT. It is important to check with your payor regarding reporting requirements. Fluoroscopic guidance is included in the descriptor of CPT 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level) and cannot be submitted for separate payment.
*This response is based on the best information available as of 3/28/19.