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Answer :
The CPT® code reported for this procedure is 64483.
This code specifically covers an epidural injection of the lumbar or sacral region performed with fluoroscopic or other imaging guidance. The code 64483 includes the injection of the anesthetic drug into the epidural space and covers the localizing and procedural aspects.
Paresthesia experienced by the patient during the procedure is a common reaction indicating that the needle is in proximity to a nerve, but does not alter the coding. This code encompasses the entire procedure, including the use of imaging techniques for precise needle placement.
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According to the question The CPT® code that should be reported for this procedure is 64483.
The provided scenario describes an epidural injection for a 37-year-old with multilevel lumbar degenerative disc disease using the transforaminal approach with fluoroscopy.
In this case, the appropriate CPT® code to report is 64483, which is used for transforaminal epidural injections performed at the lumbar or sacral level. This code covers the entire procedure, including the localization of the skin, insertion of the spinal needle, injection of anesthetic drug into the epidural space, and the use of fluoroscopy for guidance.
It is important to accurately code procedures to ensure proper documentation, billing, and reimbursement for healthcare services provided.
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