CPT codes establish a standardized language used across the United States to describe medical, surgical, and diagnostic services for billing and documentation. This system ensures consistent communication between healthcare providers, patients, and insurance payers. CPT 64483 specifically represents a Transforaminal Epidural Injection (TFEI) into the first vertebral level of the lumbar or sacral spine. The code description includes the injection of an anesthetic agent, a steroid, or both, delivered under mandatory imaging guidance. This code is used by physicians in pain management for a common intervention targeting lower back and leg pain.
The Transforaminal Epidural Injection and Its Purpose
A Transforaminal Epidural Injection (TFEI) is a minimally invasive procedure that delivers anti-inflammatory medication directly to a specific nerve root in the spine. The term “transforaminal” describes guiding the needle through the small opening, called the foramen, where a nerve root exits the spinal column. This approach allows for the precise placement of medication, typically a corticosteroid and a local anesthetic, near the irritated nerve.
The primary goal of the TFEI is to reduce inflammation and relieve radicular pain, commonly known as sciatica, which radiates from the spine into the legs or feet. This radiating pain often results from conditions that compress or irritate the nerve roots, such as a herniated or bulging disc or spinal stenosis. Delivering the medication directly to the source of the inflammation aims to provide pain relief that can last for weeks to months.
This temporary pain reduction helps the patient participate more effectively in physical therapy and other rehabilitative treatments. The procedure is not a cure for the underlying spinal condition but serves as a therapeutic tool to manage symptoms and improve mobility. It is often considered for patients whose pain has not responded adequately to conservative treatments, such as oral medications or rest.
The Procedure Steps and Imaging Guidance
The Transforaminal Epidural Injection is performed under strict sterile conditions, typically in an outpatient setting. The patient lies face down on a specialized table while the skin is cleansed. A local anesthetic is administered to numb the injection site, and a small-gauge needle is then carefully inserted toward the targeted nerve root.
A defining characteristic of the CPT 64483 procedure is the mandatory use of imaging guidance, which is explicitly included in the code’s description. This guidance is typically provided by fluoroscopy (a real-time X-ray technique) or sometimes by Computed Tomography (CT) scanning. The imaging allows the physician to visualize the needle’s path and ensure its tip is positioned accurately near the neuroforamen, the bony canal through which the nerve exits.
Once the needle position is confirmed, a small amount of radiopaque contrast dye is injected to verify the needle’s location within the epidural space. This step ensures the medication will flow around the targeted nerve root and confirms the needle has not inadvertently entered a blood vessel or the cerebrospinal fluid space. After this confirmation, the therapeutic mixture of anesthetic and steroid is injected, delivering the anti-inflammatory agents to the specific site of nerve compression.
Understanding the Specific Coding Rules
The CPT code 64483 describes an injection at a “single level” in the lumbar or sacral region. This “first level” refers to the initial spinal nerve root that receives the injection, such as the L4-L5 segment. When a patient requires injections at more than one spinal level during the same session, an additional code must be used to accurately reflect the work performed.
For each subsequent or “additional level” treated, the physician must use the add-on code CPT 64484. For example, if a patient receives injections at both the L4-L5 and L5-S1 levels, the provider bills CPT 64483 for the first level and CPT 64484 for the second level. Billing CPT 64483 multiple times is an administrative mistake that leads to claim denials, as the add-on code is designed for multi-level procedures.
If the injection is performed on both the left and right sides of the spine at the same vertebral level, it is considered a bilateral procedure. In this case, CPT code 64483 is reported with a specific modifier, often modifier -50, which indicates a bilateral service. Some insurance payers may prefer anatomical modifiers, such as -RT for the right side and -LT for the left side. Providers must verify the specific documentation requirements of each payer to ensure correct reimbursement.