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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

Fecha de vigencia original: 12/15/04

Revisado: 11/01/15

Editado: 12/17/15

Siguiente edición: ya no está programado para edición de rutina (NLR)

Tema: Inyecciones epidurales

Versión Clinica

► Descripción Declaración de posición ► Facturación/codificación ► Reembolsos
► Excepciones del programa ► Definiciones ► Guías relacionadas
► Otros ► Referencias ► Actualizaciones

 

Esta guía de cobertura médica no es una autorización, certificación, explicación de los beneficios ni garantía de pago y no constituye ni sustituye el consejo de un médico. Todas las decisiones médicas son responsabilidad exclusiva del paciente y el médico. Los beneficios se determinan por el contrato del grupo, el folleto de beneficios del asegurado o el certificado del suscriptor vigente cuando se prestaron los servicios. Esta guía de cobertura médica se aplica a todas las líneas comerciales a menos que se indique lo contrario en la sección excepciones del programa.

 

DESCRIPCIÓN:

Las inyecciones epidurales espinales terapéuticas, o los bloqueos radiculares selectivos (transforaminales), son tipos de procedimientos intervencionistas para el manejo del dolor. El uso terapéutico de las inyecciones epidurales es para el alivio a corto plazo del dolor asociado con el dolor de espalda agudo o la exacerbación del dolor de espalda crónico. Con las inyecciones terapéuticas se inyecta un corticosteroide cerca del área de interés con el objetivo de reducir el dolor. Las inyecciones epidurales deben usarse en combinación con otras modalidades de tratamiento* conservador y no como un tratamiento independiente para el alivio a largo plazo del dolor de espalda. A continuación se describen los diferentes tipos de métodos que se pueden usar para la administración de inyecciones epidurales espinales.

Inyecciones epidurales interlaminares, con esteroides, acceso al espacio epidural que está entre dos vértebras (interlaminar) para el tratamiento del dolor radicular cervical, lumbar o torácico. Estos procedimientos deben llevarse a cabo bajo guía fluoroscópica. Las inyecciones epidurales interlaminares son el tipo más común de inyección epidural.

Las inyecciones epidurales transforaminales (también conocidas como bloqueos radiculares selectivos) entran al espacio epidural a través del foramen intervertebral por donde salen los nervios espinales (región cervical, lumbar o torácica). Se usan con fines diagnósticos y terapéuticos. Estos procedimientos siempre se realizan guiados por fluoroscopia.

Las inyecciones epidurales caudales, con esteroides, se usan para el tratamiento del dolor de espalda y de las extremidades inferiores, por medio del acceso al espacio epidural que se logra a través del hiato sacro, lo que proporciona acceso a las raíces nerviosas inferiores espinales. Estos procedimientos deben llevarse a cabo bajo guía fluoroscópica. El síndrome de cirugía fallida de columna es la razón más común para usar el abordaje caudal.

DECLARACIÓN DE POSICIÓN:

Las inyecciones epidurales (caudales, interlaminares y transforaminales) con anestésicos locales y corticosteroides cumplen con la definición de necesidad médica en las siguientes indicaciones:

Dolor radicular agudo de cuello o espalda

Síndrome de cirugía fallida de columna o fibrosis epidural

Estenosis espinal o dolor crónico de cuello o espalda baja

Frecuencia de la repetición de las inyecciones epidurales terapéuticas

La aplicación de inyecciones en varias regiones o la realización de varios procedimientos durante la misma consulta no cumple con la definición de necesidad médica, a menos que se proporcione documentación de una situación inusual.

La inyección epidural bajo guía ecográfica (0228T-0231T) para cualquier indicación se considera como experimental o en fase de investigación, ya que la evidencia publicada disponible no respalda su seguridad, eficacia o valor clínico.

*El tratamiento no operatorio conservador (columna vertebral) debe incluir un abordaje multimodal integrado por una combinación de componentes activos e inactivos. Se pueden utilizar componentes inactivos, como reposo, hielo, calor, actividades modificadas, dispositivos médicos, acupuntura o estimuladores, medicamentos, inyecciones (facetarias, sin incluir los puntos gatillo) y diatermia. Las modalidades activas pueden consistir en fisioterapia, un programa de ejercicio en casa supervisado por un médico** o atención de un quiropráctico.

** Un programa de ejercicio en casa (HEP, por sus siglas en inglés) debe está integrado por los siguientes dos elementos:

1. Se le entrega información sobre un plan/prescripción de ejercicio al afiliado

2. Se lleva a cabo seguimiento (después de 4 a 6 semanas), referente a la compleción del HEP o de la incapacidad de completar el HEP por un motivo físico (por ejemplo, mayor dolor, incapacidad física de realizar los ejercicios). NOTA: la inconveniencia o incumplimiento del afiliado sin explicación no constituye incapacidad de completar un HEP.

Las contraindicaciones para las inyecciones epidurales incluyen:

• Diátesis hemorrágica y anticoagulación total (riesgo de hematoma epidural)

• Estenosis espinal grave que provoca obstrucción intraespinal

• Infección local en el lugar de la inyección

• Dolor predominantemente psicogénico

• Sepsis

• Hipovolemia

• Embarazo

• Diabetes no controlada

• Glaucoma no controlado

• Altas concentraciones de anestésico local en personas con esclerosis múltiple

• Para diagnóstico o tratamiento del dolor facetario

• Confirmación o sospecha de reacción alérgica a los esteroides

• Infección de columna

• Neoplasias malignas

Fractura aguda

INFORMACIÓN PARA FACTURACIÓN/CODIFICACIÓN:

Codificación CPT:

62310

Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid, cervical or thoracic

62311

Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

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)

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)

Códigos de diagnóstico ICD-10 que respaldan la necesidad médica: (vigencia a partir: 10/01/15)

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

M48.00

Spinal stenosis

M48.06

Spinal stenosis, lumbar region

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; high, mid cervical region; cerviothoracic region

M50.30 – M50.33

Other cervical disc degeneration

M51.04 – M51.05

Intervertebral disc disorders with myelopathy, thoracic region; thoracolumbar region

M51.06 – M51.07

Intervertebral disc disorders with myelopathy, lumbar region; lumbosacral region

M51.14 – M54.17

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

M51.34 – M51.35

Other intervertebral disc degeneration, thoracic region; thoracolumbar region

M51.36 – M51.37

Other intervertebral disc degeneration, lumbar region; lumbosacral region

M54.11 – M54.13

Radiculopathy, occipito-atlanto-axial region, cervical region, cervicothoracic region

M54.14 – M54.17

Radiculopathy, thoracic region; thoracolumbar region; lumbar region; lumbosacral 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

INFORMACIÓN DE REEMBOLSOS:

Número total de procedimientos de inyecciones epidurales:

• 62310 está limitado a seis (6) procedimiento en doce (12) meses

• 62311 está limitado a seis (6) en doce (12) meses

• 64479 y 64480, en cualquier combinación, están limitados a 6 en 12 meses

• 64483 y 64484, en cualquier combinación, están limitados a 6 en 12 meses

Epidurografía:

• 72275 está limitado a uno (1) en seis (6) meses

Códigos LOINC:

Tabla de documentación

Códigos LOINC

Código modificador LOINC del período

Descripción de los códigos modificadores LOINC del período

Evaluación inicial del médico

18736-9

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Historia clínica y examen físico

28626-0

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Nota de evolución del médico tratante

18741-9

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Radiología

18726-0

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Reporte operatorio del médico

28573-4

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Plan de tratamiento

18776-5

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Evaluación inicial de fisioterapia

18735-1

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Nota de evolución de fisioterapia

11508-9

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Medicamentos actuales, al alta o administrados

34483-8

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

EXCEPCIONES DEL PROGRAMA:

Programa para empleados federales (FEP, Federal Employee Program): seguir las pautas del FEP.

Organización de cuentas estatales (SAO, State Account Organization): seguir las pautas de SAO.

Productos Medicare Advantage: la siguiente Determinación de cobertura local (LCD, Local Coverage Determination) se revisó en la fecha de edición más reciente de la guía: Epidural (L29165) que se encuentra en fcso.com.

DEFINICIONES:

Síndrome de cirugía fallida de espalda: se caracteriza por dolor persistente o recurrente en la espalda baja, con o sin ciática, después de una cirugía lumbar; la causa más común es la fibrosis epidural.

Dolor radicular: es un tipo de dolor que se irradia hacia una extremidad directamente por el trayecto de la raíz de un nervio espinal; causado por compresión, inflamación o lesión de la raíz de un nervio espinal que surge de condiciones comunes como un disco herniado y estenosis espinal.

GUÍAS RELACIONADAS:

No corresponde ninguna.

OTROS:

No aplica.

REFERENCIAS:

  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.
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APROBACIÓN DEL COMITÉ:

Esta Guía de cobertura médica (MCG, Medical Coverage Guideline) fue aprobada por el Comité de Normas y Coberturas Médicas de BCBSF el 05/28/15.

INFORMACIÓN DE LAS ACTUALIZACIONES DE LA GUÍA:

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.

07/01/15

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

11/01/15

Revision: ICD-9 Codes deleted.

12/17/15

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

Date Printed: June 23, 2017: 06:22 PM