CPT® 64479: Injection(s), Anesthetic Agent(s) And/or Steroid; Transforaminal Epidural, With Imaging Guidance (Fluoroscopy or CT), Cervical or Thoracic, Single Level

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 64479: Transforaminal epidural steroid injection. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for CPT® 64479: Transforaminal epidural steroid injection. The quarterly edit effectiveness results from April 1, 2024, to June 30, 2024, are as follows:

Top Denial Reasons

  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination
  • The documentation submitted was incomplete and/or insufficient
  • This is a duplicate service previously submitted by a different provider

Educational Resources

Education

The physician injects an anesthetic agent and/or a long-acting corticosteroid into the epidural space using a transforaminal approach. The patient, who is sedated but awake through the intervention, is placed prone on the procedure table and the injection site sterilized with iodine or chlorhexidine. A small-gauge blunt needle is inserted through the skin and into the epidural space through the bony opening of the exiting nerve root. This approach is used primarily in the treatment of herniated discs and foraminal stenosis and requires imaging guidance by fluoroscopy or CT. The injection may be performed on one or more levels. Report 64479 for a single cervical or thoracic level (including the T12-L1 level) and 64480 for each additional level. Report 64483 for a single lumbar or sacral level and 64484 for ea ch additional level. for each additional level.

Failure To Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

Incomplete And/Or Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).

For additional educational resources, please visit our Education and Outreach department.

Last Updated Jul 31 , 2024