CPT 64483: Transforaminal Epidural Injection - Lumbar
Injection of anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance, lumbar or sacral, single level.
Documentation Requirements
- Clinical indication and failed conservative management
- Informed consent with risks discussed
- Fluoroscopic or CT guidance documented
- Needle placement with contrast confirmation
- Medication injected (agent, dose, volume)
- Level(s) injected with laterality
- Post-procedure monitoring and patient tolerance
Billing Tips
- Imaging guidance (77003) is bundled — do not bill separately
- Each additional level = 64484 (add-on code)
- Document medical necessity and failed conservative measures
- Prior authorization often required
- Bilateral injections at same level may require modifier 50
- Interlaminar epidural uses different codes (62320-62327)
Frequently Asked Questions
What documentation supports medical necessity for 64483?
Document failed conservative treatments (physical therapy, NSAIDs, activity modification), correlated imaging findings, and functional limitations. Scribeable captures these elements from your clinical encounter.
How does Scribeable support pain procedure documentation?
Scribeable generates comprehensive procedure notes with indication, consent, imaging guidance, needle placement, medications, and post-procedure assessment — all required for 64483 compliance.