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Date Printed: December 18, 2017: 11:43 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-31

Original Effective Date: 12/15/04

Reviewed: 03/23/17

Revised: 10/01/17

Subject: Epidural Injections

Clinical View

 

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION:

Therapeutic spinal epidural injections, or select nerve root blocks (transforaminal), are types of interventional pain management procedures. The therapeutic use of epidural injections is for short-term pain relief associated with acute back pain or exacerbation of chronic back pain. With therapeutic injections a corticosteroid is injected close to the target area with the goal of pain reduction. Epidural injections should be used in combination with other conservative therapy* modalities and not as stand alone treatment for long-term back pain relief. There are different approaches used when administering spinal epidural injections, described below.

Interlaminar epidural injections, with steroids, access the epidural space between two vertebrae (interlaminar) to treat cervical, lumbar or thoracic radicular pain. These procedures should be performed using fluoroscopic guidance. Interlaminar epidural injections are the most common type of epidural injection.

Transforaminal epidural injections (also called selective nerve root blocks) access the epidural space via the intervertebral foramen where the spinal nerves exit (cervical, lumbar or thoracic region). It is used both diagnostically and therapeutically. These procedures are always aided with fluoroscopic guidance.

Caudal epidural injections, with steroids, are used to treat back and lower extremity pain, accessing the epidural space through the sacral hiatus, providing access to the lower nerve roots of the spine. These procedures should be performed using fluoroscopic guidance. Failed back surgery syndrome is the most common reason for the caudal approach.

POSITION STATEMENT:

Epidural injections (caudal, interlaminar, and transforaminal) with local anesthetics and corticosteroids meet the definition of medical necessity for the following indications:

Acute radicular neck or back pain

Failed back surgery syndrome or epidural fibrosis

Spinal stenosis or chronic neck or low back pain

Frequency of repeat therapeutic epidural injection

Injecting multiple regions or performing multiple procedures during the same visit do not meet the definition of medical necessity, unless documentation of an unusual situation is provided.

Epidural injection with ultrasound guidance (0228T-0231T) for any indication is considered experimental or investigational, as the available published clinical evidence does not support safety, effectiveness or clinical value.

*Conservative non-operative therapy (spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic care.

** A home exercise program (HEP) must consist of the following two elements:

  1. Information on an exercise prescription/plan is provided to the member
  2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises).
  3. member inconvenience or noncompliance without explanation does not constitute inability to complete a HEP.

Contraindications for epidural injections include:

BILLING/CODING INFORMATION:

CPT Coding

62320

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

62321

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance

62322

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging

62323

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging

64479

Injection(s), anesthetic agent AND/OR steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

64480

Injection(s), anesthetic agent AND/OR steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

64483

Injection(s), anesthetic agent AND/OR steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

64484

Injection(s), anesthetic agent AND/OR steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (list separately in addition to code for primary procedure)

72275

Epidurography, radiological supervision and interpretation

77003

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid) (List separately in addition to code for primary procedure)

0228T

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

0229T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic, each additional level (Investigational)

0230T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral, single level (Investigational)

0231T

Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral, each additional level (Investigational)

ICD-10 Diagnoses Codes That Support Medical Necessity

B02.23

Postherpetic polyneuropathy

B02.24

Postherpetic myelitis

B02.29

Other postherpetic nervous system involvement

G54.2

Cervical root disorders

G54.3

Thoracic root disorders

G54.4

Lumbosacral root disorders

G89.12

Acute post-thoracotomy pain

G89.18

Other acute postprocedural pain

M48.00

Spinal stenosis

M48.04 – M48.08

Spinal stenosis, thoracic region; thoracolumbar region; lumbar region; lumbosacral region; sacral and sacrococcygeal region

M50.00 M50.03

Cervical disc disorder with myelopathy; unspecified cervical region; mid-cervical region; high cervical region; cerviothoracic region

M50.120 – M50.123

Mid-cervical disc disorder, unspecified; cervical disc disorder with radiculopathy, at C4-C5, C5-C6, C6-C7 levels

M50.220 – M50.223

Other cervical disc displacement mid-cervical region, unspecified level; or at C4-C5, C5-C6, C6-C7 levels

M50.30 M50.33

Other cervical disc degeneration, unspecified cervical region; mid-cervical region; high cervical region; or cervicothoracic region

M50.820 – M50.823

Other cervical disc disorders, at C4-C5, C5-C6, C6-C7 levels; or at mid-cervical region, unspecified level

M50.920 – M50.923

Unspecified cervical disc disorder, mid-cervical region, unspecified level; or at C4-C5, C5-C6, C6-C7 levels

M51.04 – M51.06

Intervertebral disc disorders with myelopathy, thoracic region; thoracolumbar region; lumbar region

M51.14 – M54.17

Intervertebral disc disorders with radiculopathy, thoracic region; thoracolumbar region; lumbar region; lumbosacral region

M51.34 – M51.37

Other intervertebral disc degeneration, thoracic region; thoracolumbar region; lumbar region; lumbosacral region

M54.11 – M54.18

Radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region; thoracic region; thoracolumbar region; lumbar region; lumbosacral region; sacral and sacrococcygeal region

M54.30 – M54.32

Sciatica, unspecified side; right side; left side

M54.40 – M54.42

Lumbago with sciatica, unspecified side; right side; left side

M96.1

Postlaminectomy syndrome

M99.22 – M99.25

Subluxation stenosis of neural canal of thoracic region; lumbar region; sacral region; pelvic region

M99.32 – M99.35

Osseous stenosis of neural canal of thoracic region; lumbar region; sacral region; pelvic region

M99.42 – M99.45

Connective tissue stenosis of neural canal of thoracic region; lumbar region; sacral region; pelvic region

M99.52 – M99.55

Intervertebral disc stenosis of neural canal of thoracic region; lumbar region; sacral region; pelvic region

M99.62 – M99.65

Osseous and subluxation stenosis of intervertebral foramina of thoracic region; lumbar region; sacral region; pelvic region

M99.72 – M99.75

Connective tissue and disc stenosis of intervertebral foramina of thoracic region; lumbar region; sacral region; pelvic region

Z79.01

Long term (current) use of anticoagulants

REIMBURSEMENT INFORMATION:

Total number of epidural injection procedures:

• 62310 is limited to six (6) procedures in twelve (12) months (code 62310 terminated 12/31/16)

• 62311 is limited to six (6) in twelve (12) months (code 62311 terminated 12/31/16)

62320 and 62321 in any combination are limited to eight (8) in twelve (12) months

62322 and 62323 in any combination are limited to eight (8) in twelve (12) months

• 64479 and 64480, in any combination, are limited to eight (8) in twelve (12) months

• 64483 and 64484, in any combination, are limited to eight (8) in twelve (12) months

Epidurography:

• 72275 is limited to one (1) in six (6) months

LOINC Codes

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician Initial assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Epidural (L29165) located at fcso.com.

DEFINITIONS:

Failed back surgery syndrome: characterized by persistent or recurring low back pain, with or without sciatica, following lumbar surgery; the most common cause is epidural fibrosis.

Radicular pain: a type of pain that radiates into an extremity directly along the course of a spinal nerve root; caused by compression, inflammation and/or injury to a spinal nerve root arising from common conditions such as herniated disc and spinal stenosis.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8744. Management of acute low back pain. Michigan Quality Improvement Consortium; Sept. 2011.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8967. Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2011 Nov.
  3. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9903. Clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. North American Spine Society; 2012.
  4. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-10140. Assessment and management of chronic pain. Institute for Clinical Systems Improvement (ICSI); 2013 Nov.
  5. American Chronic Pain Association. ACPA Consumer Guide to Pain Medication & Treatment, 2009. EPIDURALS, NERVE & FACET BLOCKS & RADIOFREQUENCY ABLATION (RHIZOTOMY). (Accessed 04/03/09).
  6. Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C; WEST Study Group. A ulticenter randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology (Oxford). 2005 Nov; 44(11): 1399-406.
  7. Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Mar 6; 68(10): 723-9. Reaffirmed July 10, 2010. (Accessed 07/31/14)
  8. Ballantyne JC, Carwood CM. Comparative efficacy of epidural, subarachnoid, and intracerebroventricular opioids in patients with pain due to cancer. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005178. DOI: 10.1002/14651858.CD005178.
  9. Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009 Jan-Feb; 12(1): 137-57.
  10. Boswell MV, Shah RV, Everett CR, Sehgal N, Mckenzie-Brown AM, Abdi S, Bowman RC, Deer TR, Datta S, Colson JD, Spillane WF, Smith HS, Lucas LF, Burton AW, Chopra P, Staats PS, Wasserman RA, Manchikanti L. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Phys 2005;8(1): 1-47.
  11. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007 Jan; 10(1): 7-111.
  12. Buenaventura RM, Datta S, Abdi S, Smith HS. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. 2009 Jan-Feb; 12(1): 233-51. Accessed 12/16/10).
  13. Care Planning:Procedures Adult InterQual® 2010. Epidural Injection.
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  17. ClinicalTrials.gov. Evaluation of the Effectiveness of Transforaminal Epidural Injections in Lumbar Disc Herniation or Radiculitis. NCT 01052571. Last updated 10/12/10.
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  21. Epstein NE. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int. 2013 Mar 22;4(Suppl 2):S74-93.
  22. Florida Medicare Part B Local Coverage Determination. L29165, Epidural, 02/02/09. Last revised 01/01/12. (Accessed 07/31/14).
  23. Gharibo CG, Varlotta GP, Rhame EE, Liu ECJ, Bendo JA, Perloff MD. Interlaminar Versus Transforaminal Epidural Steroids for the Treatment of Subacute Lumbar Radicular Pain: A Randomized, Blinded, Prospective Outcome Study. Pain Physician 2011; 14:499-511.
  24. Hayes, Inc. Hayes Medical Technology Directory™ – Epidural Steroid Injections for Low Back Pain and Sciatica. Lansdale, PA: Hayes, Inc; Oct 2005. Updated 11/11/06.
  25. Hong JH, Lee SM, Bae JH. Analysis of Inadvertent Intradiscal Injections during Lumbar Transforaminal Epidural Injection. Korean J Pain. 2014 Apr;27(2):168-73.
  26. Improving the Quality of Pain Management through Measurement and Action. Monograph developed by JCAHO as part of a collaborative project with NPC. March 2003.
  27. Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Assessment and Management of Chronic Pain. Fourth Edition. November 2009.
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  29. InterQual® 2013.2. CP: Procedures: Epidural Injection.
  30. Iversen T, Solberg TK, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ 2011;343:d5278.
  31. Jeong HS, Lee GY, Lee EG, Joe EG, Lee JW, Kang HS. Long-term assessment of clinical outcomes of ultrasound-guided steroid injections in patients with piriformis syndrome. Ultrasonography. 2015 Jan 23.
  32. Karamouzian S, Ebrahimi-Nejad A, Shahsavarani S, Keikhosravi E, Shahba M, Ebrahimi F. Comparison of two methods of epidural steroid injection in the treatment of recurrent lumbar disc herniation. Asian Spine J. 2014 Oct;8(5):646-52.
  33. Kim H-J, et al. The Efficacy of Transforaminal Epidural Steroid Injection by the Conventional Technique in Far-Lateral Herniation of Lumbar Disc. Pain Physician 2012; 15:415-420.
  34. Kim HJ, Rim BC, Lim JW, Park NK, Kang TW, Sohn MK, Beom J, Kang S. Efficacy of epidural neuroplasty versus transforaminal epidural steroid injection for the radiating pain caused by a herniated lumbar disc. Ann Rehabil Med. 2013 Dec;37(6):824-31.
  35. Kraiwattanapong C, et al. Outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar spondylolisthesis patients. Asian Spine J. 2014 Apr;8(2):119-28.
  36. Leem JG. Epidural steroid injection: a need for a new clinical practice guideline. Korean J Pain. 2014 Jul;27(3):197-9.
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  39. Manchikanti L, Buenaventura RM, et al. Effectiveness of Therapeutic Lumbar Transforaminal Epidural Steroid Injections in Managing Lumbar Spinal Pain. Pain Physician 2012; 15:E199-E245.
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  42. Manchikanti L, Cash KA, McManus CD, Damron KS, Pampati V, Falco FJE. Lumbar Interlaminar Epidural Injections in Central Spinal Stenosis: Preliminary Results of a Randomized, Double-Blind, Active Control Trial. Pain Physician 2012; 15:51-63.
  43. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic Cervical Interlaminar Epidural Injections in Managing Chronic Pain of Cervical Postsurgery Syndrome: Preliminary Results of a Randomized, Double-Blind, Active Control Trial. Pain Physician 2012; 15:13-26.
  44. Manchikanti L, Malla Y, Cash KA, McManus CD, Pampati V. Fluoroscopic Epidural Injections in Cervical Spinal Stenosis: Preliminary Results of a Randomized, Double-Blind, Active Control Trial. Pain Physician 2012; 15:E59-E70.
  45. Manchikanti L*, Cash KA, Pampati V, Wargo BW, Malla. Management of Chronic Pain of Cervical Disc Herniation and Radiculitis with Fluoroscopic Cervical Interlaminar Epidural Injections. Int. J. Med. Sci. 2012, 9.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

02/15/04

Separate MCG created for Epidural Injections from Outpatient Pain Management MCG #02-61000-01.

09/15/05

Business decision to clarify coverage criteria.

02/15/06

Scheduled review and revision of guideline consisting of updated references.

08/15/07

Review and revision of guideline consisting of updated references and reformatted guideline. MCG name changed to Epidural Injections/Infusions.

11/15/07

Review and revision of guideline consisting of updated references and addition of diagnosis codes.

05/15/09

Scheduled review; update description section to include medical necessity management statement, update position statement with coverage criteria, add medical necessity statement for fluoroscopic guidance, update limitations in reimbursement section, updated ICD 9 codes that support medical necessity, delete CPT code 62318, and 62319, and update references.

09/15/09

Revision to position statement note regarding the use epidural steroid injections. Update the limits for the total number of transforaminal injections.

01/01/10

Annual HCPCS coding update: added CPT code 77003.

02/15/10

Revision with addition of reimbursement section by adding a note in reference to CPT codes 62318 & 62319, and addition of Medicare exception statement.

05/15/10

Review with revision to position statement related to epidurography; update of CPT coding to include 72275; and update reimbursement section to include epidurography.

10/01/10

4th Quarter HCPCS coding update: ICD-9 diagnosis code 724.02 revised; ICD-9 diagnosis code 724.03 added.

10/15/10

Revision; related ICD-10 codes added.

11/15/10

Revision; Certificate of Medical Necessity added; related ICD-10 codes added; guideline reformatted.

01/01/11

Annual HCPCS coding update. Revised code descriptors for codes 64479, 64480, 64483, 64484 and 77003.

04/15/11

Scheduled review; updated description section and position statement; revised ICD-9 and ICD-10 coding sections; revised reimbursement section; updated references; added formatting changes.

07/15/11

Revision; formatting changes.

01/01/12

Annual HCPCS coding update. Revised 62310, 62311 and 77003 descriptors.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

09/15/12

Scheduled review. Revised description section, position statement, reimbursement section, definitions and Medicare Advantage program exception. Updated references and reformatted guideline.

10/15/13

Scheduled review. Revised position statement. Revised ICD9 / ICD10 coding sections and program exceptions section. Updated references.

09/15/14

Scheduled review. Position statement maintained. Updated references.

07/01/15

Scheduled review. Revised description, position statement and definitions. Updated references.

11/01/15

Revision: ICD-9 Codes deleted.

11/30/15

Update to Reimbursement Section.

12/17/15

Update to position statement (imaging guidance for all injections).

10/01/16

ICD-10 coding update: deleted codes M50.02 and M50.32; added codes M50.120 - M50.123; M50.220 - M50.223; M50.820 - M50.823; and M50.920 - M50.923.

01/01/17

Annual CPT/HCPCS update. Added 62320, 62321, 62322, 62323. Deleted 62310, 62311. Revised descriptor for 77003. Revised ICD10 coding section. Revised Reimbursement Information section.

04/15/17

Revision: updated criteria for epidural injection and criteria for frequency of injection. Revised Reimbursement Information section. Updated references.

10/01/17

Quarterly CPT/HCPCS coding update: added M48.061, M48.062.

Date Printed: December 18, 2017: 11:43 AM