Epidural Steroid Injection for Pain Management (ESI) Billing and Reimbursement
Defines billing, coding, frequency, modifier and documentation requirements for epidural steroid injections for Priority Health members; applies to providers submitting claims to Priority Health and Medicare patients where noted.
No material clinical or coverage changes in this revision.
Coverage criteria and billing rules
Coverage criteria and billing rules
Covered when all of the following coding, frequency, modifier, setting and authorization requirements are satisfied:
ALL of the following
- Only 1 spinal region may be treated per session (date of service).
- No more than 4 epidural injection sessions are allowed per spinal region in any 12-month period, regardless of number of levels treated.
ALL of the following
ALL of the following
- Modifiers should be applied when applicable per CMS NCCI and Priority Health guidance and only when supported by documentation.
Examples of modifiers
- 50 — bilateral procedure (identify bilateral procedures performed in the same operative session).
- KX — indicates requirements specified in the medical policy have been met.
- LT — left side.
- RT — right side.
ALL of the following
- Coverage will be considered only when services are furnished in an appropriate place of service based on the patient’s medical needs and condition.
- Authorization may be required depending on the setting and the member’s benefit; consult the Provider Manual for details.
ALL of the following
- For Medicare: when indications do not meet an applicable NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) is required.
- An authorization, when obtained, does not guarantee payment; medical necessity, correct coding, documentation and adherence to policy are still required.
ALL of the following
- Providers must maintain complete and thorough documentation in the medical record to substantiate the procedure; CPT/HCPCS and revenue codes may only be reported when the service was performed and fully documented to the highest level of specificity.
- Failure to follow documentation, coding or billing requirements may result in claim denial, rejection, or recoupment; Priority Health may perform payment integrity reviews (pre- or post-claim).
CPT codes, levels, and frequency limits
| 64479 | Epidural injection; lumbar (reported as primary lumbar level) |
| 64480 | Epidural injection; lumbar second level (to be reported in conjunction with 64479) |
| 64483 | Epidural injection; thoracic (reported as primary thoracic level) |
| 64484 | Epidural injection; thoracic second level (to be reported in conjunction with 64483) |
| 62321 | Injection into spinal canal, lumbar (may only be reported for 1 level per session) |
| 62323 | Injection into spinal canal, thoracic (may only be reported for 1 level per session) |
Authorization, documentation, and billing actions for providers
Authorization and PSOD
For Medicare: For indications that do not meet criteria of an NCD, local LCD or specific medical policy, a Pre-Service Organization Determination (PSOD) must be completed. See the Provider Manual for PSOD procedures and Medicare-specific requirements. Authorization may be required for services furnished in the appropriate setting to the patient's medical needs and condition.
Payment integrity and claim risk
Priority Health may perform payment integrity reviews (pre- or post-claim) to validate coding and billing accuracy and to prevent fraud, waste, and abuse. If coding, billing, documentation, government program regulations, or contractual requirements are not followed, Priority Health may reject or deny the claim and may recover or recoup claim payments. An authorization is not a guarantee of payment — claims must comply with applicable coding and documentation standards.
- Payment integrity reviews may be conducted before or after claim adjudication.
- Potential outcomes include claim denial, payment recoupment, or recovery when standards are not met.
- Claims must use industry-standard CPT, HCPCS, and revenue codes reported only when the service was performed and fully documented.
Documentation requirements
Providers are responsible for maintaining complete and thorough documentation that substantiates procedures and services billed. Documentation must support the codes reported and meet any additional requirements outlined in Priority Health's Provider Manual and applicable CMS/MDHHS guidance. Failure to document services rendered to the highest level of specificity may result in claim denial or recoupment.
Modifier billing rules
Apply modifiers according to CMS/NCCI and other applicable coding guidelines and only when supported by the medical record. Incorrect or inappropriate modifier use can result in denials or payment adjustments. Refer to the Provider Manual for full guidance.
- 50 — Bilateral procedure: identify bilateral procedures performed in the same operative session by adding modifier 50 unless otherwise specified.
- KX — Services where policy-specified requirements have been met; use when attestation or criteria in the medical policy are satisfied.
- LT — Left side: used to identify procedures performed on the left side of the body.
- RT — Right side: used to identify procedures performed on the right side of the body.
- Modifiers must be supported by documentation; this list may not be exhaustive.
Definitions
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