Following surgical
procedures including Lumbar spinal fusion require pre-authorization:
CPT 20932, 20933,20934,
20939, 20974, 20975, 20979, 22100, 22101, 22102, 22110, 22112, 22114, 22206,
22207, 22210, 22212, 22214, 22220, 22222, 22224, 22532, 22533, 22552, 22554,
22556, 22558, 22600, 22610, 22612, 22630, 22633, 22864, 22865, , , 62380, 63003,
63005, 63012, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047,
63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102,
63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, C9757).
Thoracic
laminectomy (CPT 63003, 63016, 63046) (and/or thoracic diskectomy and fusion)
(63077, 22222, 22532, 22556) require prior authorization and are considered
medically necessary for individuals with herniated discs or other causes of
thoracic nerve root compression (osteophytic spurring, ligamentous hypertrophy)
when all of the following criteria
are met:
1)
All other reasonable
sources of pain have been ruled out; and
2)
Presence of thoracic pain
secondary to nerve root or spinal cord compression with findings of weakness,
myelopathy, or sensory deficit; and
3)
Imaging studies (e.g., CT
or MRI) indicate central/lateral recess or foraminal stenosis (graded as
moderate, moderate to severe or severe; not mild or mild to moderate), or nerve
root or spinal cord compression, at the level corresponding with the clinical
findings; and
4)
Member has failed at
least 8 weeks of conservative therapy (unless there is evidence of thoracic cord
compression, or other indications for waiver of requirements for conservative
management, noted below); and
5)
Member has physical and
neurological abnormalities confirming the historical findings of nerve root or
spinal cord compression (e.g., reflex change, sensory loss, weakness) at or
below the level of the lesion and may have gait or sphincter disturbance
(evidence of thoracic radiculopathy or myelopathy); and
6)
Member`s activities of
daily living are limited by persistent pain.
Lumbar
laminectomy (63005, 63012, 63016, 63047) requires prior authorization and is
considered medically necessary for individuals with a herniated disc when
all of the following criteria are
met:
1)
All other reasonable
sources of pain have been ruled out; and
2)
Imaging studies (e.g., CT
or MRI) indicate central/lateral recess or foraminal stenosis (graded as
moderate, moderate to severe or severe; not mild or mild to moderate), or nerve
root or spinal cord compression, at the level corresponding with the clinical
findings; and
3)
Member has failed at
least 6 weeks of conservative therapy (unless there is evidence of spinal cord
compression or other indications for waiver of requirements for conservative
management, noted below); and
4)
Member`s activities of
daily living are limited by persistent pain radiating from the back down to the
lower extremity; and
5)
Presence of neurological
abnormalities (e.g., reflex change, positive straight leg raising, sensory loss,
weakness) persist on examination and correspond to the specific affected nerve
root.
QualChoice considers lumbar or thoracic laminectomy medically necessary for
any of the following:
1)
Spinal fracture,
dislocation (associated with mechanical instability), locked facets, or
displaced fracture fragment confirmed by imaging studies (e.g., CT or MRI); or
2)
Spinal infection
confirmed by imaging studies (e.g., CT or MRI); or
3)
Spinal tumor confirmed by
imaging studies (e.g., CT or MRI); or
4)
Epidural hematomas
confirmed by imaging studies (e.g., CT or MRI); or
5)
Synovial cysts, or
arachnoid cysts causing spinal cord or nerve root compression with unremitting
pain, confirmed by imaging studies (e.g., CT or MRI) and with corresponding
neurological deficit, where symptoms have failed to respond to eight weeks of
conservative therapy (unless there is evidence of cord compression, or other
indications for waiver of requirements for conservative management, noted below)
or
6)
Spinal stenosis (central,
lateral recess or foraminal stenosis) graded as moderate, moderate to severe or
severe (not mild or mild to moderate) with unremitting pain, with stenosis
confirmed by imaging studies (e.g., CT or MRI) at the level corresponding to
neurological findings, where symptoms have failed to respond to eight weeks
conservative therapy (unless there is evidence of cord compression, or other
indications for waiver of requirements for conservative management, noted
below); or
7)
Other mass lesions
confirmed by imaging studies (e.g., CT or MRI), upon individual case review.
Lumbar decompression with
or without discectomy requires prior authorization and is considered medically
necessary for rapid progression of neurological impairment (e.g., foot drop,
extremity weakness, saddle anesthesia, bladder dysfunction or bowel dysfunction)
with central, lateral recess or foraminal stenosis (graded as moderate, moderate
to severe or severe; not mild or mild to moderate) (CPT 63056) confirmed by
imaging studies (e.g., CT or MRI) at the levels corresponding to the neurologic
findings.
Vertebral corpectomy
(removal of half or more of vertebral body, not mere removal of osteophytes and
minor decompression) (63081, 63085, 63087, 63090, 63101, 63102, 63103, 63300,
63301, 63302, 63303, 63304, 63305, 63306, 63307) requires prior authorization
and is considered medically necessary in the treatment of one of the following:
1)
For tumors involving one
or more vertebrae, or
2)
Greater than 50 %
compression fracture of vertebrae, or
3)
Retropulsed bone
fragments, or
4)
Symptomatic moderate or
greater central canal stenosis caused by vertebral body pathology (such as due
to fracture, tumor or congenital or acquired deformity of the vertebral body).
Lumbar spinal fusion
(22558, 22612, 22630, 22633) requires prior authorization and is considered
medically necessary for the following:
1)
Spinal fracture repair
resulting in:
a)
Spinal instability (e.g.
burst fracture); or
b)
Neural compression.
2)
Treatment of spinal
stenosis with all of the following criteria:
a)
Postoperative instability
is likely due to extent of disease or surgery (e.g. multiple levels); and
b)
Significant stenosis
demonstrated radiographically where Imaging studies (e.g., CT or MRI) indicate
central/lateral recess or foraminal stenosis (graded as moderate, moderate to
severe or severe; not mild or mild to moderate), or nerve root or spinal cord
compression, at the level corresponding with the clinical findings;
c)
Stenosis treatment
indicated by 1 or more of the following:
i)
Progressive or severe
symptoms of neurogenic claudication; or
ii)
Leg or buttock
claudication symptoms and all of the following:
·
Symptoms are disabling;
and
·
Symptoms correlate with
imaging findings; and
·
Persistence of symptoms
for 3 months or more; and
·
Failure of 8 weeks of
intense conservative therapy to include:
(a)
Active, organized and
progressive strength and flexibility program to include formal physical therapy;
and
(b)
Less than 30% improvement
in the Oswestry Disability Index (ODI)1 or Focus On Therapeutic
Outcomes (FOTO) during the
conservative therapy; and
(c)
ODI preoperatively is
between 40% and 79% of FOTO is between 21 – 60.
A link to ODI is available
here;
http://www.rehab.msu.edu/_files/_docs/Oswestry_Low_Back_Disability.pdf
3)
Lumbar spondylolisthesis
with one or more of the following:
a)
Progressive or severe
neurologic deficits (e.g. bowel or bladder dysfunction); or
b)
Treatment is indicated by
all of the following:
i)
Persistent disabling
symptoms including:
·
Low back pain; or
·
Neurogenic claudication;
or
·
Radicular pain; and
ii)
Listhesis of at least
grade 2 is demonstrated on imaging; or radiographic documentation dynamic
instability of at least 4 mm of translation or 10 degrees of angular motion on
dynamic imaging and
iii)
Symptoms correlate with
the imaging findings; and
iv)
Symptoms have been
present at least 3 months; and
v)
Failures of 8 weeks of
intense conservative therapy; see above.
4)
Chronic disco genic back
pain with all of the following:
a)
Radicular pain; and
b)
Pain and disability for
at least 1 year; and
c)
MRI evidence of nerve
root impingement consistent with the clinical findings; and
d)
Failure of 8 weeks of
intense conservative therapy (see above).
5)
Child or adolescent with
high grade (>50% slippage) spondylolisthesis.
6)
Spinal repair and fusion
in conjunction with other procedures for neural decompression, fracture,
dislocation, infection, abscess or tumor
7)
Adult scoliosis confirmed
by imaging studies, with Cobb angle greater than 50 degrees associated with
functional impairment in skeletally mature adults, that has failed 3 months of
conservative management (unless there is evidence of lumbar cord compression, or
other indications for urgent intervention, noted below); or
8)
Adult kyphosis or which
is associated with radiological (e.g., CT or MRI) evidence of mechanical
instability or deformity of the lumbar spine that has failed 3 months of
conservative management (unless there is evidence of lumbar cord compression, or
other indications for urgent intervention, noted below); or
9)
Lumbar pseudarthrosis
(defined as absence of bridging bone that connects the vertebrae) after 12
months have elapsed since the time of fusion (unless there is evidence of lumbar
cord compression, or other indications for urgent intervention, noted below), or
if there is pseudarthrosis with additional findings of hardware failure
(movement of implants or vertebrae at site of prior attempted arthrodesis on
dynamic radiographs, or imaging evidence of fracture/disconnection/dislocation
of implants, or lucent rims around the screws on CT scan) (Note: For lumbar
pseudoarthrosis not associated with hardware failure or indications for urgent
intervention, there should be documentation of nicotine cessation, including a
nicotine blood level for persons with recent nicotine use (unless there is
evidence of lumbar cord compression, or other indications for urgent
intervention, noted below));
Thoracic spinal fusion
(CPT 22556, 22610) requires prior authorization and is considered medically
necessary for any of the following:
1)
Scoliosis confirmed by imaging studies, with Cobb angle greater than 40
degrees in skeletally immature children and adolescents, or Cobb angle greater
than 50 degrees associated with functional impairment in skeletally mature
adults, that has failed 3 months of conservative management (unless there is
evidence of thoracic cord compression, or other indications for urgent
intervention, noted below); or
2)
Thoracic kyphosis resulting in spinal cord compression, or kyphotic curve
greater than 75 degrees that is refractory to bracing, that has failed 3 months
of conservative management (unless there is evidence of thoracic cord
compression, or other indications for urgent intervention, noted below); or
3)
Thoracic pseudarthrosis (defined as absence of bridging bone that
connects the vertebrae) after 12 months have elapsed since the time of fusion
(unless there is evidence of thoracic cord compression, or other indications for
urgent intervention, noted below), or if there is pseudarthrosis with additional
findings of hardware failure (movement of implants or vertebrae at site of prior
attempted arthrodesis on dynamic radiographs, or imaging evidence of
fracture/disconnection/dislocation of implants, or lucent rims around the screws
on CT scan); or
4)
Spinal fracture, dislocation (associated with mechanical instability),
locked facets, or displaced fracture fragment confirmed by imaging studies
(e.g., CT or MRI), which may be combined with a laminectomy; or
5)
Spinal infection confirmed by imaging studies (e.g., CT or MRI) and/or
other studies (e.g., biopsy), which may be combined with a laminectomy; or
6)
Spinal tumor, primary or metastatic to spine, confirmed by imaging
studies (e.g., CT or MRI), which may be combined with a laminectomy; or
7)
Spondylolisthesis with segmental instability confirmed by imaging studies
(e.g., CT or MRI), when both of the following criteria are met:
a) Significant spondylolisthesis, grades II, III, IV, or V and
b) Symptomatic unremitting pain that has failed eight weeks of
conservative management (unless there is evidence of thoracic cord compression,
or other indications for urgent intervention, noted below); or
8)
Spinal stenosis where criteria for thoracic decompression in Section
above are met, and any of the following is met:
a) Decompression is performed in an area of segmental instability as
manifested by gross movement on flexion-extension radiographs; or
b) Decompression coincides with an area of significant degenerative
instability (e.g., scoliosis or any degree of spondylolisthesis (grades I, II,
III, IV or V); or
c) Decompression creates
an iatrogenic instability by the disruption of the posterior elements where
facet joint excision exceeds 50% bilaterally or complete excision of one facet
is performed.
Conservative
Management:
Conservative management
must be recent (within the past year) and include the following non-surgical
measures and medications unless neurologic signs are severe or rapidly
progressive:
Patient education;
Low impact exercise as
tolerated (e.g., stationary bike, swimming, walking),
Active physical therapy
for at least 6 weeks;
Medications (NSAIDS,
acetaminophen, or tricyclic antidepressants),
and (where appropriate)
identification and management of associated anxiety and depression.
Note:
The member must participate in physical
therapy for a minimum of 6 weeks duration as part of the conservative management,
unless s/he meets criteria below for
urgent intervention.
The requirement for a
trial of conservative measures may be waived in the following situations
indicating need for urgent intervention:
Spinal cord compression
or stenosis causing any of the
following:
1.
cauda equina syndrome,
2.
myelopathy,
3.
severe muscle weakness
(graded 4 minus or less on MRC scale (Note: 4 minus strength describes muscle
activation that is beyond antigravity (3/5) and produces motion against only
slight resistance and fails against moderate resistance);
4.
Instability (dynamic
excursion of greater than 1mm translation or greater than 5 degrees angulation
at an interspace);
5.
progressive neurological
deficit on serial examinations; or
6.
A discharge note from a
physical therapist documents lack of utility of further physical therapy.
NOTE:
QualChoice considers the official written report of complex imaging studies
(e.g., CT, MRI, myelogram) for medical necessity reviews. If the operating
surgeon disagrees with the official written report, the surgeon should document
that disagreement. The surgeon should discuss the disagreement with the provider
who did the official interpretation, and there should also be a written addendum
to the official report indicating agreement or disagreement with the operating
surgeon. The imaging should be performed within the past year, or after the
onset of the current constellation of symptoms or any relevant surgical
procedures, whichever is sooner.
The following procedures
are considered experimental/investigational, therefore are not covered:
-
27279, 27280 –
arthrodesis of sacroiliac joint.
-
0201T – sacroplasty
-
0202T-
Posterior vertebral joint(s) arthroplasty
-
0219T, 0220T, 0221T,
0222T, placement of posterior intrafacet implant
-
0481T injections of
autologous white blood cell concentrate
-
0274T, 0275T
Percutaneous laminotomy/laminectomy
-
22867, 22868, 22869,
22870 and HCPC C1821 Interspinous/interlaminar process stabilization/spacer
device and its removal.
Codes Used In This BI:
20552
Inj(s); sgl or mult trigger point(s), 1-2 muscles(s) [no repeats > every 7
days, up to 4 sets to diagnose & achieve therap effect, no addtl sets if no
clinical resp, once diagnosed & therapeutic effect achieved, no repeats > 1
every 2 mths, & beyond 12 mths req clinical rvw]
20553
Inj(s); sgl or mult trigger point(s), 3+ muscles(s) [no repeats > every 7
days, up to 4 sets to diagnose & achieve therap effect, no addtl sets if no
clinical response, once diagnosed & therap effect achieved, no repeats > 1 every
2 mths, & beyond 12 mths req clinical rvw]
20690
Application of a uniplane, unilat, extrnl fixatn syst
20692
Application of a multiplane, unilat, extrnl fixatn syst
20693
Adjstmt or revsn of extrnl fixatn syst req anesthesia &/or new ring(s) or
bar(s)
20694
Remvl, under anesthesia, of extrnl fixatn syst
20900
Bone graft, any donor area; minor or small (e.g., dowel or button)
20902
Bone graft, any donor area; major or large
20926
Tissue grafts, other (e.g., paratenon, fat, dermis) [not cvd during lumbar
dcmprsn laminectomy/discectomy] Deleted code eff 01/01/2020
+
20930
Allograft, morselized, or plcmnt of osteopromotive material, for spine
surgery only
+
20931
Allograft, structural, for spine surgery only
+
20932
Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf;
osteoarticular, incl articular surface & contiguous bone
+
20933
Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf;
hemicortical intercalary, partial (i.e., hemicylindrical)
+
20934
Allograft, incl templating, cutting, plcmnt & intrnl fixatn, when perf;
intercalary, complete (i.e., cylindrical)
+
20936
Autograft for spine surgery only; local obtained frm same incision
+
20937
Autograft for spine surgery only; morselized (thru sep skin or fascial
incision)
+
20938
Autograft for spine surgery only; structural, bicortical or tricortical (thru
sep skin or fascial incsn)
+
20939
Bone marrow aspiration for bone autografting, spine surgery only
20955
Bone graft with microvascular anastomosis; fibula
20962
Bone graft with microvascular anastomosis; other than fibula, iliac crest, or
metatarsal
20974
Electrical stimulation to aid bone healing; noninvasive (nonoperative)
20975
Electrical stimulation to aid bone healing; invasive (operative)
20979
Low intensity ultrasound stimulation to aid bone healing, noninvasive
(nonoperative)
+
22103
Partl excsn of posterior vrtbrl component (e.g., spinous process, lamina or
facet) for intrinsic bony lesion, sgl vrtbrl sgmt; ea addl sgmt
+
22116
Partl excsn of vrtbrl body, for intrinsic bony lesion, w/o dcmprsn of spinal
cord or nerve root(s), sgl vrtbrl sgmt; ea addtl vrtbrl sgmt
+
22208
Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vrtbrl
sgmt; ea addtl vrtbrl sgmt
+
22216
Osteotomy of spine, posterior or posterolateral approach, 1 vrtbrl sgmt; ea
addtl vrtbrl sgmt
+
22226
Osteotomy of spine, incl discectomy, anterior appr, sgl vrtbrl sgmt; ea addtl
vrtbrl sgmt
22533
Arthrodesis, lateral extracavitary techn, incl minimal discectomy to prepare
intrspc (othr than for dcmprsn); lumbar
+
22534
Arthrodesis, lateral extracavitary techn, incl minimal discectomy to prepare
intrspc (othr than for dcmprsn); thoracic or lumbar, ea addtl vrtbrl sgmt
+
22552
Arthrodesis, anterior interbody, incl disc space prep, discectomy,
osteophytectomy & dcmprsn of spinal cord &/or nerve roots; cervical below C2, ea
addtl intrspc
22558
Arthrodesis, anterior interbody techn, incl minimal discectomy to prepare
intrspc (other than for decmprsn); lumbar
+
22585
Arthrodesis, anterior interbody techn, incl minimal discectomy to prepare
intrspc (other than for dcmprsn); ea addtl intrspc
22612
22610
Arthrodesis, posterior or posterolateral techn, sgl lvl; lumbar (w/lateral
trnsvrs techn, when perf)
Arthrodesis, post or posterolateral tech, single level; thoracic (w/lateral
transverse tech, when performed)
+
22614
Arthrodesis, posterior or posterolateral techn, sgl lvl; ea addtl vrtbrl sgmt
22630
Arthrodesis, posterior interbody techn, incl laminectomy &/or discectomy to
prepare intrspc (other than for dcmprsn), sgl intrspc; lumbar
+
22632
Arthrodesis, posterior interbody technique, incl laminectomy &/or discectomy
to prepare intrspc (other than for dcmprsn), sgl intrspc; ea addtl intrspc
22633
Arthrodesis, combined posterior or posterolateral techn w/posterior interbody
techn incl laminectomy &/or discectomy sufficient to prepare intrspc (other than
for dcmprsn), sgl intrspc & sgmt; lumbar
22818
Kyphectomy, circumferential exposure of spine & resection
of vrtbrl sgmt(s) (incl body & posterior elements); sgl or 2 sgmts
22819
Kyphectomy, circumferential exposure of spine & resection of vrtbrl sgmt(s)
(incl body & posterior elements); 3+ sgmts
22830
Exploration of spinal fusion
+
22840
Posterior non-segmntl instrumntn (e.g., Harrington rod techn, pedicle fixatn
across 1 intrspc, atlantoaxial transarticular screw fixatn, sublaminar wiring at
C1, facet screw fixatn)
+
22841
Intrnl spinal fixatn by wiring of spinous processes
+
22842
Posterior segmntl instrmntn (e.g., pedicle fixatn, dual rods w/mult hooks &
sublaminar wires); 3-6 vrtbrl sgmts
+
22843
Posterior segmntl instrmntn (e.g., pedicle fixatn, dual rods w/mult hooks &
sublaminar wires); 7-12 vrtbrl sgmts
+
22844
Posterior segmntl instrmntn (e.g., pedicle fixation, dual rods w/mult hooks &
sublaminar wires); 13+ vrtbrl sgmts
+
22845
Anterior instrmntn; 2-3 vrtbrl sgmts
+
22846
Anterior instrmntn; 4-7 vrtbrl sgmts
+
22847
Anterior instrmntn; 8+ vrtbrl sgmts
+
22848
Pelvic fixatn (attachment of caudal end of instrumentation to pelvic bony
structures) other than sacrum
22849
Reinsertion of spinal fixation device
22850
Rmvl of posterior nonsgmtl instrumentation (e.g., Harrington rod)
22852
Rmvl of posterior sgmtl instrumentation
22855
22864
22865
Removal of anterior instrumentation
Rmvl of total disc arthroplasty (artificial disc), ant approach, single
interspace; cervical;
Rmvl of total disc arthroplasty (artificial disc), ant approach, single
interspace; lumbar
22867
Insertn of interlaminar/interspinous process stabilization/distraction dvc,
w/out fusn, incl img guid, when perfor, w/open dcmprsn, lumbar; sgl lvl
+
22868
2nd level
22869
Insertn of interlaminar/interspinous process stabilization/distraction dvc,
w/out open dcmprsn or fusn, incl img guid when perf, lumbar; sgl lvl
+
22870
2nd level
27080
Coccygectomy, primary
27096
Inj proc for sacroiliac jt, arthrography &/or anesthetic/steroid [up to 2 inj
to diagnose & achieve therapeutic effect, no repeats > once every 7 days, no
addtl inj > once every 2 mths or beyond 12 mths]
27279
Arthrodesis, sacroiliac jt, percut or minimally invasv (indir visualizatn),
w/img guid, incl obtaining bone graft when perf, & plcmt of transfixing dvc
27280
Arthrodesis, open, sacroiliac jt, incl obtaining bone graft, incl
instrumentation, when perf
62263
Percut lysis of epidural adhesions using solution inj (e.g., hypertonic
saline, enzyme) or mechanical means (eg, catheter) incl radiologic localization
(incl contrast when admin), mult adhesiolysis sessions; 2+ days
62264
Percut lysis of epidural adhesions using solution inj (e.g., hypertonic
saline, enzyme) or mechanical means (eg, catheter) incl radiologic localization
(incl contrast when admin), mult adhesiolysis sessions; 1 day
62267
Percut aspiration w/in the nucleus pulposus, intervrtbrl disc, or paravrtbrl
tissue for diag purposes
62280
Inj/infsn of neurolytic subst, w/ or w/out other therap subst; subarachnoid
ultrasonic guid for needle plcmt, img supv & interpr [not covd for chemical
ablation of facet jts]
62281
Inj/infsn of neurolytic subst, w/ or w/out other therap subst; epidural,
cervical or thoracic [not cvd for chemical ablation (incl but not ltd to
alcohol, phenol or sodium morrhuate) of facet jts]
62282
Inj/infsn of neurolytic subst, w/ or w/out other therap subst; epidural,
lumbar, sacral (caudal) [not cvd for chemical ablation (incl but not ltd to
alcohol, phenol or sodium morrhuate) of facet jts]
62287
Dcmprsn proc, percut, of nucleus pulposus of intervrtbrl disc, any method,
sgl or mltpl lvls, lumbar (e.g., manual or automated percut discectomy, percut
laser discectomy)
62292
Inj proc for chemonucleolysis, inclg discography, intervrtbrl disc, sgl or
mult lvls, lumbar
62302
Myelography via lumbar inj, incl radiological supv & interpret; cervical
62303
Myelography via lumbar inj, incl radiological supv & interpret; thoracic
62304
Myelography via lumbar inj, incl radiological supv & interpret; lumbosacral
62305
Myelography via lumbar inj, incl radiological supv & interpret; 2+ regions
62320
Inj, of diag or therap subst, not incl neurolytic subst, incl needle or
catheter plcmt, interlaminar epidural or subarachnoid, cervical or thoracic; w/o
img guid
62321
Inj, of diag or therap subst, not incl neurolytic subst, incl needle or
catheter plcmt, interlaminar epidural or subarachnoid, cervical or thoracic;
w/img guid (ie, fluoroscopy or CT)
62322
Inj, of diag or therap subst, not incl neurolytic subst, incl needle or
catheter plcmt, interlaminar epidural or subarachnoid, lumbar or sacral
(caudal); w/o img guid
62323
Inj, of diag or therap subst, not incl neurolytic subst, incl needle or
catheter plcmt, interlaminar epidural or subarachnoid, lumbar or sacral
(caudal); w/img guid (ie, fluoroscopy or CT)
62324
Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of
diag or therap subst, not incl neurolytic subst, interlaminar epidural or
subarachnoid, cervical or thoracic; w/o img guid
62325
Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of
diag or therap subst, not incl neurolytic subst, interlaminar epidural or
subarachnoid, cervical or thoracic; w/img guid (ie, fluoroscopy or CT)
62326
Inj, incl indwelling catheter plcmt, contin infsn or intermittent bolus, of
diag or therap subst, not incl neurolytic subst, interlaminar epidural or
subarachnoid, lumbar or sacral (caudal); w/o img guid
62327
Inj, incl indwell catheter plcmt, contin infsn or intermittent bolus, of diag
or therap subst, not incl neurolytic subst, interlaminar epidural or
subarachnoid, lumbar or sacral (caudal); w/img guid (ie, fluoroscopy or CT)
62380
Endoscopic dcmprsn of spinal cord, nerve root(s), incl laminotomy, prtl
facetectomy, foraminotomy, discectomy &/or excsn of herniated intervrtbrl disc,
1 intrspc, lumbar
+
63035
Laminotomy (hemilaminectomy), w/dcmprsn of nerve root(s), incl prtl
facetectomy, foraminotomy &/or excision of herniated intervrtbrl disc; ea addtl
intrspc, cervical or lumbar
+
63043
ea addtl cervical intrspc
+
63044
ea addtl lumbar intrspc
+
63048
ea addtl sgmt, cervical, thoracic, or
lumbar
+
63057
Transpedicular approach w/dcmprsn of spinal cord, equina &/or nerve(s) (eg,
herniated intrvrtbrl disc), sgl sgmt; ea addtl sgmt, thoracic or lumbar
+
63066
Costovertebral approach w/dcmprsn of spinal cord or nerve root(s), (e.g.,
herniated intervertebral disk), thoracic; ea addtl sgmt
+
63076
cervical, ea addtl intrspc
+
63078
ea addtl intrspc
+
63082
cervical, ea addtl sgmt
+
63086
Vrtbrl corpectomy (vrtbrl body resection), prtl or cmplt, trnsthoracic
approach w/dcmprsn of spinal cord and/or nerve root(s); thoracic, ea addtl sgmt
+
63088
Vrtbrl corpectomy (vrtbrl body resection), prtl or cmplt, combined
thoracolumbar approach w/dcmprsn of spinal cord, cauda equina or nerve root(s),
lwr thoracic or lumbar; ea addtl sgmt
+
63091
Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, transperitoneal or
retroperitoneal approach w/dcmprsn of spinal cord, cauda equina or nerve
root(s), lwr thoracic, lumbar, or sacral; ea addtl sgmt
+
63103
Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, lateral
extracavitary approach w/dcmprsn of spinal cord &/or nerve root(s) (e.g., for
tumor or retropulsed bone fragments); thoracic or lumbar, ea addtl sgmt
+
63308
Vrtbrl corpectomy (Vrtbrl body resection), prtl or cmplt, for excsn of
intrspnl lesion, sgl sgmt; ea addtl sgmt
64420
INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL (Revised code eff 01/01/2020)
64421
INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL
(Revised code eff 01/01/2020)
64450
INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
(Revised code eff 01/01/2020)
64479
Injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or
thoracic, single level (code revised eff 01-01-2021)
+
64480
ea addtl lvl
64483
Injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or
sacral, single level (code revised eff 01-01-2021)
+
64484
ea addtl lvl
64490
Inj, diagnostic or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves
innervating that joint) w/img guid (fluoroscopy or CT), cervical or thoracic;
sgl lvl
+
64491
2nd lvl
+
64492
3rd & any addtl lvl(s)
64493
Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves
innervating that joint) w/img guid (fluoroscopy or CT), lumbar or sacral; sgl
lvl
+
64494
2nd lvl
+
64495
3rd & any addtl lvl(s)
64633
Destruction by neurolytic agent, paravrtbrl facet jt nerve(s), w/img guid
(fluoroscopy or CT); cervical or thoracic, sgl facet jt [not cvd for cooled
radiofrequency ablation]
+
64634
cervical or thoracic, ea addtl facet joint [not
cvd for cooled radiofrequency ablation]
64635
lumbar or sacral, sgl facet joint [not cvd for cooled radiofrequency
ablation]
+
64636
lumbar or sacral, ea addtl facet joint [not cvd for cooled radiofrequency
ablation]
64712
Inj, anesthetic agent; other peripheral nerve or branch [coccygeal ganglion
(ganglion impar) block]
+
69990
Operating microscope
0200T
Percut sacral augmentation (sacroplasty), unilat inj(s), incl the use of a
balloon or mechanical device, when used, 1+ needles, incl img guid & bone
biopsy, when perf
0201T
Percut sacral augmentation (sacroplasty), bilat inj, incl the use of a
balloon or mechan dvc, when used, 2+ needles, incl img guid & bone biopsy, when
perf
0202T
Posterior vrtbrl joint(s) arthroplasty (e.g., facet joint[s] rplcmt) incl
facetectomy, laminectomy, foraminotomy & vrtbrl column fixtn, w/ or w/out inj of
bone cement, incl fluoroscopy, sgl lvl, lumbar spine
0213T
Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves
innervating that joint) w/ultrasnd guid, cervical or thoracic; sgl lvl
+
0214T
2nd lvl
+
0215T
3rd & any addtl lvls
0216T
Inj, diag or therap agt, paravrtbrl facet (zygapophyseal) jt (or nerves
innervating that joint) w/ultrasnd guid, lumbar or sacral; sgl lvl
+
0217T
2nd lvl
+
0218T
3rd & any addtl lvls
0219T
Plcmt of a posterior intrafacet implant(s), unilat or bilat, incl img & plcmt
of bone graft(s) or synthetic dvc(s), sgl lvl; cervical
0220T
thoracic
0221T
lumbar
+
0222T
ea addtl vrtbrl sgmt
0274T
Percutaneous laminotomy/laminectomy (intralaminar approach) for decmprsn of
neural elements, any method under indir img guid, w/ or w/o the use of an
endoscope, sgl or mltpl lvls, unilat or bilat; cervical or thoracic
0275T
lumbar
0481T
Inj, autologous white blood cell concentrate (autologous protein solution),
any site, incl img guid, harvesting & prep, when perf
C2614
Probe, percut lumbar discectomy
C9752
Destruction of intraosseous basivrtbrl nerve, first 2 vertebral bodies, incl
img guid (e.g., fluoroscopy), lumbar/sacrum
C9753
Destruction of intraosseous basivrtbrl nerve, ea addtl vrtbrl body, incl img
guid (e.g., fluoroscopy), lumbar/sacrum
G0259
Inj proc for sacroiliac joint; arthrography
G0260
Inj proc for sacroiliac jt; prvsn of anesthetic, steroid &/or other
therapeutic agt, w/ or w/out arthrography
G0276
Blinded proc for lumbar stenosis, percut img-hyphenguided lumbar dcmprsn
(PILD) or placebo-hyphencontrol, perf in an aprvd cvg w/evidence dvlpmt (CED)
clinical trial
S2348
Decmprsn proc, percut, of nucleus pulposus of intervrtbrl disc, using
radiofreq energy, sgl or mltpl lvls, lumbar
S2350
Discectomy, anterior, w/decmprsn of spinal cord &/or nerve root(s), incl
osteophytectomy; lumbar, sgl intrspc
+
S2351
Discectomy, anterior, w/decmprsn of spinal cord &/or nerve root(s), incl
osteophytectomy; lumbar, ea addtl intrspc
C9757
Laminotomy (hemilaminectomy), with decompression of nerve
root(s), including partial facetectomy, foraminotomy and excision of herniated
intervertebral disc, and repair of annular defect with implantation of bone
anchored annular closure device, including annular defect measurement, alignment
and sizing assessment, and image guidance; 1 interspace, lumbar
62328
DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT
62329
THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT
64451
INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG
64454
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG