CPT® Code 0228T | Case2Code

Code deleted, see 64999

Official Description

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

Common Language Description

A transforaminal epidural injection is a medical procedure designed to alleviate pain associated with conditions such as foraminal stenosis and large or lateral disc herniations. This procedure involves the precise delivery of an anesthetic agent and/or steroid into the epidural space, which is the area surrounding the spinal cord and nerve roots. The injection is guided by ultrasound to ensure accurate placement, enhancing the effectiveness of the treatment. During the procedure, the patient is typically positioned in a prone (face down) position on a treatment table to facilitate access to the cervical or thoracic vertebrae. The use of fluoroscopic guidance allows the physician to visualize the needle's trajectory as it is advanced through the skin and into the nerve root foramen of the affected vertebra. Once the needle is correctly positioned within the epidural space, contrast material is injected to confirm proper placement before administering the anesthetic and/or steroid. This procedure is coded as 0228T for the first injection at a cervical or thoracic vertebral level, while subsequent injections at additional levels are coded as 0229T.

1. Indications

The transforaminal epidural injection procedure is indicated for the following conditions:

Foraminal Stenosis - A narrowing of the foraminal space where nerve roots exit the spinal column, which can lead to nerve compression and pain.
Large or Lateral Disc Herniations - The displacement of disc material that can impinge on nearby nerve roots, causing pain, numbness, or weakness in the extremities.

2. Procedure

The transforaminal epidural injection procedure involves several key steps to ensure accurate delivery of the anesthetic agent and/or steroid.

Step 1: Patient Positioning - The patient is positioned in a prone (face down) position on the treatment table to provide optimal access to the cervical or thoracic vertebrae that require treatment.
Step 2: Needle Insertion - Using fluoroscopic guidance, the physician carefully advances a needle through the skin and into the nerve root foramen of the affected vertebra. This step is critical for ensuring that the needle reaches the correct anatomical location.
Step 3: Contrast Injection - Once the needle is in place, contrast material is injected to confirm that the needle is correctly positioned within the epidural space. This step is essential for verifying the accuracy of the injection site.
Step 4: Injection of Anesthetic and/or Steroid - After confirming proper needle placement, the physician injects the anesthetic agent and/or steroid into the epidural space. This medication aims to reduce inflammation and alleviate pain associated with the underlying conditions.

3. Post-Procedure

After the transforaminal epidural injection, patients are typically monitored for a short period to assess their response to the procedure and to ensure there are no immediate complications. Patients may experience some relief from pain shortly after the injection, although the full effect may take several days to manifest. It is important for patients to follow any post-procedure care instructions provided by their healthcare provider, which may include activity restrictions and recommendations for pain management. Additionally, patients should be informed about potential side effects and when to seek medical attention if necessary.

Short Descr	NJX TFRML EPRL W/US CER/THOR
Medium Descr	NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL
Long Descr	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
Status Code	Carriers Price the Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Procedure or Service, Multiple Reduction Applies
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P6D - Minor procedures - other (non-Medicare fee schedule)
MUE	Not applicable/unspecified.
CCS Clinical Classification	231 - Other therapeutic procedures