Painful Spinal Hardware

Question:

Our physician injected 0.5% Marcaine and 80 mg of Depo-Medrol to existing spinal hardware (eg, pedicle screws) at L4, L5, and S1 bilaterally for a patient complaining of painful hardware. Can CPT code 64483 be reported? 

Answer:

No. CPT code 64483, (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), represents transforaminal epidural nerve root injection performed in the lumbar region. There is no specific CPT code for the injection of spinal hardware. CPT code 64999, Unlisted procedure, nervous system, would be most appropriate to describe the injections for pain performed outside the foramen, as indicated in the clinical scenario provided in this inquiry. Although three spinal level (L4, L5, S1 bilaterally) injections were performed, code 64999 should be reported only once to represent the multiple injections. 

*This response is based on the best information available as of 5/9/24.