64483

Transforaminal Epidural Injection of Anesthetic and/or Steroid, Lumbar or Sacral, Single Level

CPT code 64483 describes a specialized interventional pain management procedure involving the transforaminal epidural injection of an anesthetic agent and/or a corticosteroid at a single lumbar or sacral level. Unlike the interlaminar approach, which enters the epidural space through the midline, the transforaminal approach targets the neural foramen where the specific nerve root exits the spinal canal. This technique allows for a more concentrated delivery of medication to the ventral epidural space and the specific nerve root that is typically the source of radicular symptoms. The procedure is performed under direct visualization using imaging guidance, specifically fluoroscopy or computed tomography (CT), which is considered an integral component of the service and cannot be billed separately. The physician begins by positioning the patient, usually in a prone or slightly oblique position, and identifies the target vertebral level. After sterile preparation and local anesthesia of the skin, a spinal needle is advanced under real-time guidance toward the 'safe triangle' or the target zone of the neural foramen. To ensure safety and accuracy, a small amount of radiopaque contrast material is injected to perform an epidurogram. This step confirms that the needle is not positioned intravascularly or intrathecally and verifies that the medication will spread appropriately along the nerve root. Once the needle placement is confirmed, a therapeutic mixture of a corticosteroid (to reduce inflammation) and a local anesthetic (to provide immediate diagnostic or therapeutic relief) is injected. The transforaminal approach is highly effective for localized radiculopathy caused by herniated discs, foraminal stenosis, or lateral recess stenosis, and it serves both diagnostic and therapeutic purposes in managing chronic low back and leg pain.

Clinical Indications

  • Lumbar radiculopathy (sciatica)
  • Lumbar spinal stenosis with neurogenic claudication
  • Herniated nucleus pulposus with nerve root impingement
  • Foraminal or lateral recess stenosis
  • Post-laminectomy syndrome (Failed Back Surgery Syndrome)
  • Degenerative disc disease causing radicular pain
  • Spondylolisthesis with associated nerve root compression
  • Diagnostic evaluation of a specific nerve root's contribution to pain

Procedure Steps

  1. Obtain informed consent and perform a pre-procedure time-out.
  2. Position the patient in a prone or prone-oblique position on a radiolucent procedure table.
  3. Use fluoroscopy to identify the target lumbar or sacral vertebral level and the neural foramen.
  4. Aseptically prepare and drape the injection site.
  5. Administer local anesthetic to the skin and subcutaneous tissues.
  6. Advance a spinal needle (typically 22 or 25 gauge) under fluoroscopic guidance toward the superior-posterior aspect of the neural foramen (the '6 o'clock' position of the pedicle).
  7. Verify the needle tip position in both Anteroposterior (AP) and Lateral fluoroscopic views.
  8. Inject radiopaque contrast medium to confirm epidural spread and rule out intravascular, intrathecal, or intra-neural uptake.
  9. Slowly inject the therapeutic mixture of corticosteroid and local anesthetic.
  10. Remove the needle and apply a sterile dressing; monitor the patient for immediate adverse reactions or neurological changes.

Coding Guidelines

  • Imaging guidance (fluoroscopy or CT) and all related hardware/software for the guidance are included in code 64483 and should not be reported separately.
  • Code 64483 is used for the first (initial) level of a lumbar or sacral transforaminal injection.
  • For each additional lumbar or sacral level injected, use add-on code 64484 in conjunction with 64483.
  • If the procedure is performed bilaterally at the same level, append modifier 50 to code 64483.
  • Do not report 64483 in conjunction with 64479 or 64480 for the same spinal level.
  • The use of contrast material is included in the procedural work and is not separately billable.
  • If ultrasound guidance is used instead of fluoroscopy or CT, the procedure should be coded using 0230T (though 64483 specifically requires fluoroscopy or CT).

Associated ICD-10 Codes