Summary & Overview
CPT 64480: Transforaminal Cervical or Thoracic Epidural Injection, Additional Level
CPT code 64480 denotes a transforaminal epidural injection of an anesthetic and/or steroid in the cervical or thoracic spine for each additional level beyond the primary injection. This interventional pain management procedure is performed to deliver medication directly into the neural foramen to address radicular pain and inflammation. Its use has implications for clinical pathways, utilization oversight, and payer coverage policies across the country.
Key payers referenced in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a national view of how payers classify and reimburse this service, common billing practices, and the clinical context for using transforaminal injections in the cervical and thoracic regions.
Readers will find benchmarks for utilization and reimbursement practices where available, summaries of relevant policy considerations, and clinical context that clarifies when additional-level coding with 64480 is indicated. The report also identifies common modifiers used in practice and highlights areas where documentation and coding specificity affect coverage determinations. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 64480 describes an injection of an anesthetic agent and/or steroid delivered as a transforaminal epidural injection in the cervical or thoracic region. The code specifically applies to each additional level after the initial transforaminal epidural injection level.
Service type: Interventional pain management procedure (transforaminal epidural injection, cervical/thoracic, additional level)
Typical site of service: Outpatient procedure suite, ambulatory surgery center, or hospital outpatient department
Clinical & Coding Specifications
Clinical Context
A 52-year-old patient presents with unilateral radicular neck and upper extremity pain radiating in a C6 distribution after months of degenerative disc disease and foraminal stenosis documented on MRI. Conservative measures including oral analgesics, physical therapy, and a prior medial branch block provided insufficient relief. The interventional pain specialist schedules a cervical transforaminal epidural steroid injection to deliver a mixture of local anesthetic and corticosteroid into the affected neural foramen to reduce inflammation around the affected nerve root.
The clinical workflow includes pre-procedure evaluation (history, focused neurologic exam, review of imaging, informed consent), pre-procedure medication reconciliation and allergy check, procedural sedation or monitored anesthesia as indicated, sterile fluoroscopic-guided needle placement into the transforaminal epidural space at the target cervical level, contrast injection to confirm epidural spread, injection of anesthetic and steroid, post-procedure monitoring for neurologic or hemodynamic complications, and documentation of level(s) treated, medications and volumes, fluoroscopy use, and patient response. Billing claims report the initial transforaminal cervical/ thoracic level as the primary code and add additional levels with the per-add-on level code as appropriate. Typical site of service is an ambulatory surgery center or hospital outpatient department; it may also occur in an office-based procedure suite with appropriate imaging and monitoring capabilities.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
59 |