Translaminar Vs. Transforaminal

Translaminar Vs. Transforaminal Injections - CPT Coding

62311 - Translaminar Injection CPT

ENCODER:

The patient is placed in a sitting or lateral decubitus position for the physician to insert a needle into the vertebral interspace of the lumbar or sacral region. The site to be entered is sterilized, local anesthesia is administered and the needle is inserted. Contrast media may be injected to confirm proper needle placement under fluoroscopy. The physician injects a solution to provide a therapeutic or diagnostic outcome. The solution is injected into the epidural or subarachnoid space. With the procedure complete the needle is removed and the wound is dressed.

AMA:

Description of Procedure:

An injection needle is directed into the subarachnoid or epidural space at the proper vertebral level, under x-ray fluoros-copy, as necessary. Care is taken to avoid damaging any nerve roots, cauda equina, or the spinal cord. A contrast injec-tion is performed as necessary to confirm the location of the needle tip or catheter and to determine the degree of free flow of liquid in the space to assure both safety and accuracy. The therapeutic injection(s) is performed through the same needle. The injection needle is removed and a sterile dressing applied.

64483 - Transforaminal Injection CPT

ENCODER:

The physician injects anesthetic and/or steroid into the epidural space using a transforaminal approach. This approach is used primarily in the treatment of herniated discs and requires separately reportable fluoroscopic direction. The injection may be performed on a single or multiple lumbar or sacral level. Report 64483 for a single level, report 64484 for each additional level.

AMA:

Description of Procedure:

Under intravenous anesthetic, the affected foramen is identified and the skin is infiltrated with a local anesthetic. A needle is directed lateral to midline under fluoroscopic guidance into the foramen. Both anteroposterior and oblique or lateral views are needed to get depth as well as an anterior and posterior position. Contrast injection is performed to confirm the location of the needle tip. Once this is completed, an anesthetic agent and/or steroid is injected. The injection needle is removed and a sterile dressing is applied.