CPT® Code 0230T | Case2Code

Code deleted, see 64999

Official Description

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; 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 of the lumbar or sacral region of the spine. The patient is typically positioned in a prone (face down) position on a treatment table to facilitate access to the targeted area. Utilizing ultrasound guidance, the physician carefully advances a needle through the skin and into the nerve root foramen of the affected vertebra, ensuring accurate placement within the epidural space. The use of contrast material is critical during this process, as it confirms the correct positioning of the needle before the injection of the therapeutic agents. The primary code for billing this procedure when performed at a single lumbar or sacral level is 0230T. For any additional levels that may require injection, the code 0231T should be utilized.

1. Indications

Transforaminal epidural injections are indicated for the treatment of specific spinal conditions that cause pain and discomfort. The following conditions are explicitly mentioned as indications for this procedure:

Foraminal Stenosis - A narrowing of the foraminal space where nerve roots exit the spinal column, leading 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 lower extremities.

2. Procedure

The transforaminal epidural injection procedure involves several critical steps to ensure effective treatment. Each step is outlined as follows:

Step 1: Patient Positioning - The patient is positioned in a prone position on the treatment table to provide optimal access to the lumbar or sacral region of the spine.
Step 2: Needle Insertion - Using ultrasound guidance, the physician carefully advances a needle through the skin and into the nerve root foramen of the targeted vertebra. This step is crucial for accurately reaching the epidural space.
Step 3: Contrast Injection - Once the needle is in place, a contrast agent is injected to confirm that the needle is correctly positioned within the epidural space. This step is essential for ensuring the safety and efficacy of the injection.
Step 4: Injection of Therapeutic Agents - After confirming proper needle placement, an anesthetic agent and/or steroid is injected into the epidural space to provide pain relief and reduce inflammation.

3. Post-Procedure

Following the transforaminal epidural injection, patients may experience immediate relief from pain, although some may have a temporary increase in discomfort due to the procedure itself. It is important for patients to be monitored for any adverse reactions or complications. Post-procedure care typically includes instructions for activity modification, pain management, and follow-up appointments to assess the effectiveness of the injection. Patients are advised to avoid strenuous activities for a specified period to allow for optimal recovery.

Short Descr	NJX TFRML EPRL W/US LUMB/SAC
Medium Descr	NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL
Long Descr	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; 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