Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Failed conservative treatment not documented for at least 3 months
Very Common64483 (epidural steroid injection) denials occur when documentation doesn't show adequate conservative treatment trial. Most insurance policies require documented failure of oral medications, physical therapy, and activity modification for 3+ months before approving injection.
Common Causes
- • Injection requested without PT trial documented
- • Only pain medication tried - no comprehensive treatment program
- • Conservative treatment <6 weeks - insufficient trial period
Resolution Strategy
Appeal with comprehensive conservative treatment documentation: PT records showing 6-12 weeks participation without significant improvement (attendance, exercises, ROM/pain scores), medication trials with adequate dosing and duration (NSAIDs at therapeutic doses for 2-4 weeks, gabapentin or pregabalin titrated to effective dose for neuropathic pain, muscle relaxants if spasm component), activity modification attempts (work restrictions, ergonomic changes, lifestyle modifications documented). If acute severe radiculopathy with progressive neurologic deficit (foot drop, saddle anesthesia, severe weakness), may argue expedited injection appropriate to prevent permanent neurologic damage. Most successful appeals show 3+ months comprehensive conservative care failure.
2. Frequency limits exceeded - too many injections same location within 12 months
CommonMost insurance policies limit epidural steroid injections to 3-4 per year per spinal region. Denials occur when frequency limits exceeded, especially if prior injections provided only short-term relief suggesting injections not effective therapy for this patient.
Common Causes
- • 4th or 5th injection same location within 12 months
- • Prior injections provided <6 weeks relief - not effective
- • Injections <6 weeks apart - too frequent
Resolution Strategy
Appeal with documentation showing: prior injections provided significant sustained relief (6+ months pain reduction), patient made meaningful functional gains from injections (return to work, improved sleep, reduced opioid use), new imaging showing worsening pathology justifying additional injection (MRI showing larger disc herniation), or different spinal level requiring injection. If prior injections provided only brief relief (<4-6 weeks), appeal unlikely successful - patient not good candidate for repeat injections. Alternative treatments: surgical consultation (if structural problem requiring repair), spinal cord stimulator trial (for chronic refractory radiculopathy), multimodal pain management program. Most policies enforce strict annual limits.
3. Same-day bilateral injections denied as medically unnecessary
CommonWhen bilateral transforaminal epidural injections performed same session (both sides same level), insurance may deny one side arguing risk/benefit ratio doesn't support bilateral injections simultaneously. Concern about bilateral complications (weakness, sensory loss affecting both legs).
Common Causes
- • Bilateral L5 or S1 radiculopathy - both sides injected same day
- • Insurance policy explicitly limits to unilateral injection per session
- • No documentation of why bilateral injection necessary vs staged injections
Resolution Strategy
Most payers deny bilateral same-day injections as medical necessity issue. Appeal arguing: patient unable to return for second procedure (lives far from facility, transportation barriers, severe disability making multiple procedures difficult), bilateral severe symptoms requiring simultaneous treatment for functional improvement, or procedure performed with continuous fluoroscopic guidance minimizing complication risk. If denied, schedule second side 2-4 weeks after first - allows assessment of response and avoids bilateral complication risk. Most policies reimburse second side at 50% when billed bilaterally.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Transforaminal epidural injection with imaging guidance at single lumbar or sacral level
Common Scenarios
Documentation Requirements
- Level of injection documented
- Imaging guidance documented
- Anesthetic/steroid documented
- Patient response to procedure
Coding Guidelines
Common Modifiers
Bundling Rules
- Single level only
- Includes imaging guidance
- Includes anesthetic and/or steroid
Exclusions
- Do not bill if multiple levels (use add-on codes)
- Do not bill imaging guidance separately
Coding Notes
Related CPT Codes
Clinical scenarios
- Level of injection documented
- Imaging guidance documented
- Anesthetic/steroid documented
- Level of injection documented
- Imaging guidance documented
- Anesthetic/steroid documented
- Level of injection documented
- Imaging guidance documented
- Anesthetic/steroid documented
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Ask a QuestionFrequently Asked Questions
CPT 64483 is the billing code for "Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level". Transforaminal epidural injection with imaging guidance at single lumbar or sacral level
Medicare pays approximately $236.13 for CPT 64483 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 64483 has a total RVU of 6.20, broken down as: Work RVU 2.50, Practice Expense RVU 3.50, and Malpractice RVU 0.20. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 64483 is "Failed conservative treatment not documented for at least 3 months". 64483 (epidural steroid injection) denials occur when documentation doesn't show adequate conservative treatment trial. Most insurance policies require documented failure of oral medications, physical therapy, and activity modification for 3+ months before approving injection. Common causes include: Injection requested without PT trial documented; Only pain medication tried - no comprehensive treatment program. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 64483 include: Level of injection documented; Imaging guidance documented; Anesthetic/steroid documented; Patient response to procedure. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 64483: Single level only. Includes imaging guidance Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 64483 include: 59 (Distinct procedural service when multiple procedures performed), 50 (Bilateral procedure), LT (Left side). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 64483 is Typically 20-30 minutes. Time-based codes require documentation of the actual time spent providing the service.