CPT® Code 0231T | Case2Code

Official Description

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

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 fluoroscopic guidance, which provides real-time imaging, a needle is carefully advanced through the skin and into the nerve root foramen of the affected vertebra. This technique ensures that the needle is accurately placed within the epidural space. Once the needle is in position, a contrast agent is injected to confirm the correct placement before administering the anesthetic and/or steroid. It is important to note that CPT® Code 0231T is specifically used for each additional level of injection performed after the primary procedure, which is coded separately with CPT® Code 0230T for the first injection at a lumbar or sacral vertebral level.

1. Indications

The transforaminal epidural injection is indicated for patients experiencing specific conditions that lead to pain and discomfort in the lumbar or sacral regions. These indications include:

Foraminal Stenosis - A condition where the openings through which spinal nerves exit the vertebral column become narrowed, leading to nerve compression and pain.
Large or Lateral Disc Herniations - Occurs when the inner gel-like core of a spinal disc protrudes through a tear in the outer layer, potentially pressing on nearby nerves and causing significant pain and discomfort.

2. Procedure

The procedure for a transforaminal epidural injection involves several critical steps to ensure safety and efficacy. The following procedural steps are outlined:

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 for the injection.
Step 2: Imaging Guidance - Fluoroscopic guidance is employed to visualize the anatomy and ensure accurate needle placement. This imaging technique allows the physician to see the spinal structures in real-time.
Step 3: Needle Insertion - A needle is carefully advanced through the skin and into the nerve root foramen of the targeted vertebra. This step requires precision to avoid damaging surrounding tissues.
Step 4: 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 crucial for verifying the accuracy of the injection site.
Step 5: Injection of Anesthetic and/or Steroid - 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

After the transforaminal epidural injection, patients are typically monitored for a short period to assess for any immediate adverse reactions. It is common for patients to experience some relief from pain shortly after the procedure, although the full effect may take several days to manifest. Patients may be advised to rest and avoid strenuous activities for a brief period following the injection. Additionally, follow-up appointments may be scheduled to evaluate the effectiveness of the treatment and determine if further injections or alternative therapies are necessary.

Short Descr	NJX TFRML EPRL W/US LUMB/SAC
Medium Descr	NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL
Long Descr	Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)
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	Items and Services Packaged into APC Rates
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