Coding for Epidural Steroid Injections

Epidural steroid injections are used to treat pain in the back, neck, arms, and legs caused by inflammation of the spinal nerves associated with spinal nerve compression. Spinal nerve compression is seen with conditions such as spinal stenosis, spondylolysis, or disc herniation. To reduce inflammation, corticosteroids such as dexamethasone are administered to spinal nerves through injection into the epidural space. Sometimes a local anesthetic, such as lidocaine, is also injected. While most epidural steroid injections are performed in the outpatient setting and reported with CPT codes, they may also be performed during inpatient admissions and reported with ICD-10-PCS codes. Coding for both CPT and PCS is discussed below.

CPT

CPT codes for epidural steroid injections are reported from the range 62320-62327 and are divided along three criteria; Method of administration, anatomic site, and use of imaging guidance.

Method of Administration: Codes 62320-62323 report injection by needle or non-indwelling catheter. Codes 62324-62327 report injection by indwelling catheter, continuous infusion, or intermittent bolus.

Anatomic site: Within the groups of codes for each administration method, codes are differentiated by cervical or thoracic epidural space (62320-62321, 62324-62325) and lumbar or sacral epidural space (62322-62323, 62326-62327).

Imaging guidance:  Within the groups of codes for both anatomic sites, codes are available to report injections performed either with (62321, 62323, 62325, 62327) or without imaging guidance (62320, 62322, 62324, 62326) (i.e., fluoroscopy or CT).

Key coding points:

• When imaging guidance is used, injection of contrast for guidance is included in the work reported by the “with imaging guidance” codes and is not separately reportable.
• These codes are used to report administration of various non-neurolytic, diagnostic or therapeutic substances. Codes are reported only once even if multiple substances are administered during a single injection.
• Code choice is based on the region where the needle/catheter enters the body. Codes are reported only once even if the substance spreads or the catheter tip moves into another spinal region.

PCS

Reporting epidural steroid injections in ICD-10-PCS requires “building” a code with the appropriate value for each of the 7 PCS characters. All epidural steroid injections will have the same value for each character as follows:

1. Section: 3 Administration
2. Body System: E Physiological Systems and Anatomical Regions
3. Root Operation: 0 Introduction
4. Body System/Region: R Spinal Canal*
5. Approach: 3 Percutaneous
6. Substance: 3 Anti-inflammatory
7. Qualifier: Z No Qualifier

The final code is 3E0R33Z.

In accordance with AHA Coding Clinic Fourth Quarter ICD-10 2014 Page: 45, if a combination of corticosteroid and anesthetic is administered into the spinal canal by a single epidural injection, a separate PCS code may be reported for each substance. The value of the 6th character will vary dependent on the substances administered.
For example, if lidocaine is injected along with dexamethasone the final code for the lidocaine injection would be 3E0R3BZ, with the 6th character of “B” specifying that the substance administered is a local anesthetic.

Whether you’re coding in CPT or ICD-10-PCS, reporting epidural steroid injections can be a breeze if you have all the right documentation elements and follow the coding guidance available in the CPT/PCS codebook.

*The ICD-10-PCS body part key classifies “Epidural Space” as either “intracranial” or “spinal”. “Spinal Canal” is the body region that corresponds to “Epidural space, spinal”. Note that the body region is the same regardless of which region of the spinal column (Lumbar, Thoracic or Cervical) is being injected.

Epidural space or intracranial:Use Epidural Space
Epidural space or cranial:Use Spinal Canal