E/M levels are selected based on either Medical Decision Making (MDM) or Total Time spent on the date of the encounter.
A "New Patient" has not received any professional services from the provider (or another provider of the exact same specialty/subspecialty in the same group) within the past 3 years.
99201 (DELETED): This code was retired in 2021. New billers often see it in old manuals, but it is no longer valid. If a visit is "Level 1," you must now use 99202.
99202 (Straightforward MDM): 15–29 minutes. Used for minor issues (e.g., a simple localized muscle strain).
[ 99203 (Low MDM): 30–44 minutes]
99204 (Moderate MDM): 45–59 minutes. The "workhorse" for pain management, as patients usually have multiple chronic conditions or require complex treatment planning.
99205 (High MDM): 60–74 minutes. Used for extremely complex cases or when extensive records from multiple outside specialists must be reviewed.
99211 (Minimal Complexity): Often called the "Nurse Visit."
The Nuance: This is the only E/M code that does not require a physician to be in the room. It is used for services like a blood pressure check or a quick dressing change by a nurse under physician supervision. It does not have a time requirement in the descriptor.
99212 (Straightforward MDM): 10–19 minutes. Used for very brief follow-ups where the condition is stable (e.g., a quick check on a healing trigger point site).
99213 (Low MDM): 20–29 minutes.
[ 99214 (Moderate MDM): 30–39 minutes ] Standard for regular follow-ups for chronic pain patients with fluctuating symptoms.
MORE DETAILS ....
✅ PASS (Audit-Safe) Example
Assessment/MDM (E/M):
New patient evaluated for lumbar radiculopathy with 6-month history, worsening despite PT and medications. Independent history, exam, and MRI review performed. Treatment options discussed. Decision made today to proceed with ESI due to persistent symptoms and functional limitation.
Billing:
99204-25 (New patient E/M)
62323 (ESI)
Why it passes:
✔ Separate clinical decision
✔ Not pre-scheduled solely for injection
✔ Clear medical necessity
Documentation:
Patient presents for scheduled lumbar ESI. Consent obtained. Procedure performed without complication.
Billing:
99204-25 + ESI ❌
Why it fails:
✘ No distinct evaluation
✘ No new decision-making
✘ Visit solely procedural
Documentation:
Reviewed prior notes. Patient continues pain. Proceeded with planned ESI.
Issue:
Minimal MDM; decision appears pre-determined.
New complaint or worsening condition
Separate history + exam + MDM
Explicit statement: “Decision to perform ESI made today”
Avoid phrases like “patient here for scheduled injection”
One-Line Safe Phrase
“Following a comprehensive new-patient evaluation, the decision was made today to proceed with ESI due to failure of conservative management.”
E/M levels are selected based on either Medical Decision Making (MDM) or Total Time spent on the date of the encounter.
A "New Patient" has not received any professional services from the provider (or another provider of the exact same specialty/subspecialty in the same group) within the past 3 years.
99201 (DELETED): This code was retired in 2021. New billers often see it in old manuals, but it is no longer valid. If a visit is "Level 1," you must now use 99202.
99202 (Straightforward MDM): 15–29 minutes. Used for minor issues (e.g., a simple localized muscle strain).
[ 99203 (Low MDM): 30–44 minutes]
99204 (Moderate MDM): 45–59 minutes. The "workhorse" for pain management, as patients usually have multiple chronic conditions or require complex treatment planning.
99205 (High MDM): 60–74 minutes. Used for extremely complex cases or when extensive records from multiple outside specialists must be reviewed.
99211 (Minimal Complexity): Often called the "Nurse Visit."
The Nuance: This is the only E/M code that does not require a physician to be in the room. It is used for services like a blood pressure check or a quick dressing change by a nurse under physician supervision. It does not have a time requirement in the descriptor.
99212 (Straightforward MDM): 10–19 minutes. Used for very brief follow-ups where the condition is stable (e.g., a quick check on a healing trigger point site).
99213 (Low MDM): 20–29 minutes.
[ 99214 (Moderate MDM): 30–39 minutes ] Standard for regular follow-ups for chronic pain patients with fluctuating symptoms.
MORE DETAILS ....
✅ PASS (Audit-Safe) Example
Assessment/MDM (E/M):
New patient evaluated for lumbar radiculopathy with 6-month history, worsening despite PT and medications. Independent history, exam, and MRI review performed. Treatment options discussed. Decision made today to proceed with ESI due to persistent symptoms and functional limitation.
Billing:
99204-25 (New patient E/M)
62323 (ESI)
Why it passes:
✔ Separate clinical decision
✔ Not pre-scheduled solely for injection
✔ Clear medical necessity
Documentation:
Patient presents for scheduled lumbar ESI. Consent obtained. Procedure performed without complication.
Billing:
99204-25 + ESI ❌
Why it fails:
✘ No distinct evaluation
✘ No new decision-making
✘ Visit solely procedural
Documentation:
Reviewed prior notes. Patient continues pain. Proceeded with planned ESI.
Issue:
Minimal MDM; decision appears pre-determined.
New complaint or worsening condition
Separate history + exam + MDM
Explicit statement: “Decision to perform ESI made today”
Avoid phrases like “patient here for scheduled injection”
One-Line Safe Phrase
“Following a comprehensive new-patient evaluation, the decision was made today to proceed with ESI due to failure of conservative management.”
HEAD / FACE Atypical facial pain: G50.1 Cervicogenic headache / Suboccipital headache: R51 Cluster headache (not intractable): G44.009 Occipital neuralgia / headache: M54.81 Spinal headache: G97.1 Temporomandibular joint dysfunction (unspecified): M26.60 Tension headache: G44.209 Trigeminal neuralgia: G50.0
CERVICAL SPINE Cervicalgia (neck pain): M54.2 Degenerative disc disease (cervical) C2-C6 (High cervical DDD): M50.31 C6-C7 (Mid cervical DDD): M50.32 C7-T1 DDD: M50.33 Disc herniation (cervical) C2-C6 (High cervical): M50.21 C6-C7 (Mid cervical): M50.22 C7-T1: M50.23 Dystonia / Torticollis: M43.6 Facet syndrome (cervical): M54.02 Failed back syndrome (post-laminectomy) cervical: M96.1 Radiculopathy Cervical: M54.12 Cervicothoracic: M54.13 Radiculopathy 2/2 disc herniation (High cervical C2-C6): M50.11 Radiculopathy 2/2 disc herniation (Mid cervical C6-C7): M50.12 Radiculopathy 2/2 disc herniation (C7-T1): M50.13 Spinal stenosis (cervical): M48.02 Spondylosis (cervical) Spondylosis w/o radiculopathy or myelopathy: M47.812 Spondylosis with radiculopathy (w/o myelopathy): M47.22 Spondylolisthesis cervical: M43.12 Spondylolisthesis cervicothoracic: M43.13 Sprain of ligaments of cervical spine (whiplash): S13.4xxA / S13.4xxD Strain of muscle, fascia, tendons (cervical): S16.1xxA / S16.1xxD
THORACIC SPINE Back pain (thoracic): M54.6 Compression fracture (pathologic 2/2 osteoporosis) Other osteoporosis with current pathological fracture of vertebrae: M80.88 Collapsed vertebrae (Thoracic): M48.54xA / M48.54xD Collapsed vertebrae (Thoracolumbar T12-L1): M48.55xA / M48.55xD Degenerative disc disease (Thoracic): M51.34 Degenerative disc disease (Thoracolumbar T12-L1): M51.35 Disc herniation (Thoracic): M51.24 Disc herniation (Thoracolumbar T12-L1): M51.25 DISH (Diffuse idiopathic skeletal hyperostosis): M48.10 Failed back syndrome (post-laminectomy) thoracic: M96.1 Intercostal neuropathy: G58.0 Radiculopathy (thoracic) Thoracic radiculopathy: M54.14 Thoracic radiculopathy 2/2 disc herniation: M51.14 Thoracolumbar radiculopathy 2/2 disc herniation (T12-L1): M51.15 Rib sprain: S23.41xA / S23.41xD Scoliosis (including kyphoscoliosis): M41 Spinal stenosis (thoracic): M48.04 Spondylosis w/o radiculopathy or myelopathy (thoracic): M47.814 Spondylosis with myelopathy (thoracic): M47.14 Sprain of ligaments (thoracic spine): S23.3xxA / S23.3xxD Syrinx (syringomyelia): G95.0 Thoracic outlet syndrome (TOS): G54.0
LUMBAR SPINE Ankylosing spondylitis (lumbar spine): M45.6 Arachnoiditis (unspecified meningitis): G03.9 Bertolotti's syndrome: Q76.49 Compression fracture (pathologic 2/2 osteoporosis) Age-related osteoporosis with current pathological fracture of vertebrae: M80.08 Collapsed vertebrae (Lumbar): M48.56xA / M48.56xD Degenerative disc disease (Lumbar): M51.36 Degenerative disc disease (L5-S1): M51.37 Disc herniation (Lumbar): M51.26 Disc herniation (L5-S1): M51.27 Disc herniation with myelopathy (lumbar): M51.06 Facet syndrome (Lumbar): M54.06 Facet syndrome (L5-S1): M54.07 Failed back syndrome (post-laminectomy) lumbar: M96.1 Iliolumbar syndrome / sprain of lumbar ligaments: S33.5xxA / S33.5xxD Low back pain (Lumbago): M54.5 Lumbosacral plexopathy: G54.4 Radiculopathy (Lumbar): M54.16 Radiculopathy (L5-S1): M54.17 Radiculopathy 2/2 disc herniation (Lumbar): M51.16 Radiculopathy 2/2 disc herniation (L5-S1): M51.17 Spinal stenosis (central) Lumbar central stenosis with or w/o neurogenic claudication: M48.061 Lumbar central stenosis WITH neurogenic claudication: M48.062 L5-S1 central stenosis with or w/o neurogenic claudication: M48.07 Lumbar central stenosis 2/2 disc herniation: M99.53 Spinal stenosis (foraminal) lumbar 2/2 facet joint spurs and spondylolisthesis: M99.63 2/2 disc bulge and soft tissue: M99.73 Spondylolisthesis (Lumbar): M43.16 Spondylolisthesis (L5-S1): M43.17 Spondylolysis (congenital): Q76.2 Spondylolysis (acquired): M43.06 Spondylosis w/o myelopathy or radiculopathy (Lumbar): M47.816 Spondylosis w/o myelopathy or radiculopathy (L5-S1): M47.817 Spasm of back muscles: M62.830 Sprain (lumbar): S33.5xxA / S33.5xxD Strain (lumbar): S39.012
SACRUM / BUTTOCKS Cluneal neuroma (neuralgia/neuritis unspecified): M79.2 Coccydynia: M53.3 Piriformis syndrome with sciatica LEFT: G57.02 / RIGHT: G57.01 Sacroiliac joint disorder/pain (arthropathy unspecified): M12.9 Sacroiliac joint sprain: S33.6xA / S33.6xD Sacroiliitis: M46.1 Sacral and sacrococcygeal spondylosis: M47.818
PELVIS / HIP / THIGH Arthritis (osteoarthritis) of the hip LEFT: M25.752 / RIGHT: M25.751 Bursitis ischial / ischiogluteal LEFT: M70.72 / RIGHT: M70.71 Bursitis trochanteric LEFT: M70.62 / RIGHT: M70.61 Femoral neuropathy LEFT: G57.22 / RIGHT: G57.21 Gluteal tendinitis LEFT: M76.02 / RIGHT: M76.01 Hamstring strain LEFT: S76.312A / RIGHT: S76.311A Iliotibial band syndrome LEFT: M76.32 / RIGHT: M76.31 Meralgia paresthetica LEFT: G57.12 / RIGHT: G57.11 Pain in the hip LEFT: M25.552 / RIGHT: M25.551 Pain in the leg LEFT: M79.605 / RIGHT: M79.604 Piriformis syndrome with sciatica LEFT: G57.02 / RIGHT: G57.01
KNEE Bursitis prepatellar LEFT: M70.42 / RIGHT: M70.41 Bursitis pes anserine LEFT: M70.52 / RIGHT: M70.51 Chondromalacia patella LEFT: M22.42 / RIGHT: M22.41 Pain in knee LEFT: M25.562 / RIGHT: M25.561 Patellar tendinitis LEFT: M76.62 / RIGHT: M76.61 Peroneal neuropathy LEFT: S84.12xA / RIGHT: S84.11xA
ANKLE / FOOT Achilles tendinitis / bursitis LEFT: M76.62 / RIGHT: M76.61 Metatarsalgia LEFT: M77.42 / RIGHT: M77.41 Morton's neuroma LEFT: G57.62 / RIGHT: G57.61 Pain in ankle / foot LEFT: M25.572 / RIGHT: M25.571 Plantar fasciitis: M72.2 Tarsal tunnel syndrome LEFT: G57.52 / RIGHT: G57.51
OTHER LOWER EXTREMITY CRPS type I LEFT: G90.522 / RIGHT: G90.521 / BILATERAL: G90.523 CRPS type II (causalgia) LEFT: G57.72 / RIGHT: G57.71
SHOULDER Adhesive capsulitis (frozen shoulder) LEFT: M75.02 / RIGHT: M75.01 Bicipital tendinitis LEFT: M75.22 / RIGHT: M75.21 Bursitis subacromial LEFT: M75.52 / RIGHT: M75.51 Bursitis scapulothoracic LEFT: M75.82 / RIGHT: M75.81 Impingement of shoulder LEFT: M75.42 / RIGHT: M75.41 Labral tear LEFT: S43.432A / RIGHT: S43.431A Osteoarthritis of shoulder LEFT: M25.712 / RIGHT: M25.711 Pain in arm LEFT: M79.602 / RIGHT: M79.601 Pain in shoulder LEFT: M25.512 / RIGHT: M25.511 Paresthesia of skin: R20.2 Sprain of sternoclavicular joint: S23.420A / S23.420D Strain of rotator cuff LEFT: S46.012 / RIGHT: S46.011
ELBOW Lateral epicondylitis (tennis elbow) LEFT: M77.12 / RIGHT: M77.11 Medial epicondylitis (golfer's elbow) LEFT: M77.02 / RIGHT: M77.01 Median neuropathy LEFT: G56.12 / RIGHT: G56.11 Olecranon bursitis LEFT: M70.22 / RIGHT: M70.21 Radial neuropathy LEFT: G56.32 / RIGHT: G56.31
WRIST / HAND Carpal tunnel syndrome LEFT: G56.02 / RIGHT: G56.01 Cubital tunnel syndrome LEFT: G56.22 / RIGHT: G56.21 De Quervain's tenosynovitis: M65.4 Osteoarthritis of wrist LEFT: M19.032 / RIGHT: M19.031 Osteoarthritis of hand LEFT: M19.042 / RIGHT: M19.041 Trigger finger: M65.30 Wrist drop (acquired) LEFT: M21.332 / RIGHT: M21.331
OTHER UPPER EXTREMITY CRPS type I LEFT: G90.512 / RIGHT: G90.511 / BILATERAL: G90.513 CRPS type II (causalgia) LEFT: G56.42 / RIGHT: G56.41
RHEUMATOLOGIC Ankylosing spondylitis T/L: M45.5 / Lumbar: M45.6 / L5-S1: M45.7 Dermatomyositis (unspecified with myopathy): M33.92 Gout (unspecified site): M10.00 Polymyalgia rheumatica: M35.3 Polymyositis (with myopathy): M33.22 Rheumatoid arthritis (unspecified): M06.9 Systemic lupus erythematosus (unspecified): M32.9
PSYCH Anxiety: F41.1 Depression (major depressive disorder, recurrent, unspecified): F33.9 Insomnia (unspecified): G47.00 Restless leg syndrome: G25.81
EMG / NCS Carpal tunnel syndrome LEFT: G56.02 / RIGHT: G56.01 Cubital tunnel syndrome LEFT: G56.22 / RIGHT: G56.21 Diabetic amyotrophy type I: E10.44 / type II: E11.44 Lumbosacral plexopathy: G54.4 Neuralgic amyotrophy (Parsonage-Turner): G54.5 Neuropathy drug-induced (chemotherapy): G62.0 Pain in arm LEFT: M79.602 / RIGHT: M79.601 Pain in leg LEFT: M79.605 / RIGHT: M79.604 Peripheral neuropathy: G60.9 Radial neuropathy LEFT: G56.32 / RIGHT: G56.31 Skin hyperesthesia: R20.3 Skin hypoesthesia: R20.1 Skin paresthesia: R20.2 Tarsal tunnel syndrome LEFT: G57.52 / RIGHT: G57.51 Thoracic outlet syndrome (TOS): G54.0
MISCELLANEOUS Atrophy from disuse (unspecified site): M62.50 Chronic pain syndrome: G89.4 Constipation slow transit: K59.01 / opioid-induced: K59.09 Costochondritis: M94.0 Edema localized: R60.0 / generalized: R60.1 Fibromyalgia: M79.1 Gait abnormality (unsteadiness): R26.81 GERD: K21.9 Muscle spasm (other): M62.838 Myalgia: M79.7 Muscle weakness (generalized): M62.81 Obesity morbid: E66.01 / overweight: E66.3 Osteoporosis (age-related w/o fracture): M81.0 Peripheral vascular disease (unspecified): I73.9 Poor balance: R26.2 Post-herpetic neuralgia: B02.29 Rib sprain: S23.41xA Skin hyperesthesia: R20.3 Skin hypoesthesia: R20.1 Skin paresthesia: R20.2 Testosterone deficiency: E29.1 Vitamin D deficiency: E55.9
7TH POSITION OPTIONS A = Initial visit D = Subsequent visit S = Sequela of the original injury
EVALUATION & MANAGEMENT (E&M) New Patients Straightforward – 10 min: 99201 Straightforward – 20 min: 99202 Low complexity – 30 min: 99203 Moderate complexity – 45 min: 99204 High complexity – 60 min: 99205
Established Patients Brief – 5 min: 99211 Straightforward – 10 min: 99212 Low complexity – 15 min: 99213 Moderate complexity – 25 min: 99214 High complexity – 40 min: 99215 Independent Medical Examination (IME): 99456
EPIDURAL STEROID INJECTIONS (ESI) Interlaminar (fluoroscopy included — cannot bill separately) Cervical or Thoracic interlaminar: 62321 Lumbar or Sacral interlaminar (caudal): 62323 Transforaminal (fluoroscopy included — cannot bill separately) Cervical or Thoracic — first level: 64479 Cervical or Thoracic — each additional level: 64480 Lumbar or Sacral — first level: 64483 Lumbar or Sacral — each additional level: 64484 Ex: Bilateral L5 TF ESI = 64483-50
FACET JOINT INJECTIONS / MEDIAL BRANCH BLOCKS (MBB) (Fluoroscopy included — cannot bill separately) Cervical or Thoracic — 1st level: 64490 Cervical or Thoracic — 2nd level: 64491 Cervical or Thoracic — 3rd level: 64492 Lumbar or Sacral — 1st level: 64493 Lumbar or Sacral — 2nd level: 64494 Lumbar or Sacral — 3rd level: 64495 Ex: Bilateral L3-L4-L5 MBB = 64493-50, 64494-50 Note: Bill per complete facet joint. Max 3 joints per side typically reimbursed. Note: TON + C3 MBB = one full joint (C2/3) = 64490 Ex: Right TON, C3, C4, C5 = 64490, 64491, 64492
RADIOFREQUENCY ABLATION (RFA) (Fluoroscopy included — cannot bill separately) Cervical or Thoracic — 1st joint: 64633 Cervical or Thoracic — each additional joint: 64634 Lumbar or Sacral — 1st joint: 64635 Lumbar or Sacral — each additional joint: 64636
SACROILIAC JOINT (SIJ) SIJ injection without fluoroscopy: 20552 (billed as trigger point) SIJ injection with fluoroscopy: 27096 Sacral lateral branch blocks: 64450 (bill 77003 with these) RFA of L5 dorsal primary ramus: 64635 RFA of S1 lateral branches: 64640 RFA of S2 lateral branches: 64640 RFA of S3 lateral branches: 64640 Fluoroscopic needle guidance S1-S3 lateral branches: 77003
JOINTS & BURSA — INJECTION OR ASPIRATION Major joint/bursa (knee, hip, shoulder, trochanteric, subacromial, pes anserine): 20610 Intermediate joint/bursa (TMJ, acromioclavicular, wrist, elbow, ankle, olecranon): 20605 Minor joint/bursa (fingers PIP/DIP, toes): 20600 Fluoroscopic needle guidance (non-spinal): 77002 Shoulder arthrogram injection: 23350 + 77002 Hip arthrogram injection: 27093 + 77002 Carpal tunnel injection: 20526
TENDONS, LIGAMENTS & MUSCLE Tendon sheath or ligament (iliolumbar, trigger finger, De Quervain's, plantar fascia): 20550 Tendon origin/insertion: 20551 Trigger point injection — 1 or 2 muscles: 20552 Trigger point injection — 3 or more muscles: 20553 Intramuscular injection: 96372
NERVE BLOCKS Greater occipital nerve: 64405 Lesser occipital nerve: 64450 Other peripheral nerve (superior cluneal, genicular, SI lateral branch): 64450 Suprascapular nerve: 64418 Intercostal nerve — single: 64420 Intercostal nerve — multiple: 64421 Ilioinguinal and Iliohypogastric nerve: 64425 Trigeminal nerve (any branch): 64400 Sphenopalatine ganglion: 64505 Stellate ganglion (cervical sympathetic): 64510 Superior hypogastric plexus: 64517 Thoracic or lumbar paravertebral sympathetic / ganglion impar: 64520 Celiac plexus: 64530 Plantar common digital nerve (Morton's neuroma): 64455 Genicular nerve blocks: 64450 x3 units Genicular nerve RFA: 64640, 64640-59, 64640-59 Unlisted procedure: 64999
BOTULINUM TOXIN Botulinum toxin type A — Botox/Dysport (per unit): J0585 Botulinum toxin type B — Myobloc (per 100 units): J0587 EMG guidance during chemodenervation: 95874 Chemodenervation — neck muscles (spasmodic torticollis): 64616 Chemodenervation — trunk/extremity (CP, dystonia, MS): 64614 Chemodenervation — facial/trigeminal/cervical/accessory nerves bilateral (chronic migraine): 64615
INJECTABLES (J-CODES) Note: J1030 and J1040 deleted April 1, 2024 — replaced by J1010 Depo-Medrol / Methylprednisolone acetate (per 1 mg): J1010 Note: Bill units = mg administered. Ex: 40mg = J1010 x 40 units. Include NDC on claim. Kenalog / Triamcinolone (per 10 mg): J3301 Dexamethasone sodium phosphate (per mg): J1100 Celestone (per 3 mg): J0702 Celestone (per 4 mg): J0704 Note: S0020 deleted June 30, 2023 — replaced by J0665 Bupivacaine / Marcaine NOS (per 0.5 mg): J0665 Note: Bill units = mg ÷ 0.5. Ex: 30mg = 60 units. Include JW or JZ modifier. Note: J2001 deleted — replaced by J2003 Lidocaine HCl (per 1 mg): J2003 Note: Use J2004 if lidocaine contains epinephrine. Omnipaque 300 (per ml): Q9967 Omnipaque 240 (per ml): Q9966 Toradol / Ketorolac (per 15 mg): J1885 (add 96372 if IM) Methocarbamol / Robaxin (up to 10 ml): J2800 (add 96372 if IM) Versed (per mg): J2250 Fentanyl (0.1 mg): J3010 Diphenhydramine / Benadryl (up to 50 mg): J1200 Synvisc 3-dose (per 2 ml syringe): J7325 Synvisc One (per 6 ml syringe): J7325S
FLUOROSCOPY & IMAGING GUIDANCE Fluoroscopic needle guidance — spinal: 77003 Fluoroscopic needle guidance — non-spinal: 77002 CT needle guidance: 77012 Note: Fluoro cannot be billed separately with ESI, facet, MBB, or RFA codes.
MODIFIERS -50: Bilateral -52: Incomplete procedure (reduced service — stopped for reasons other than patient well-being) -53: Incomplete procedure (physician elected to terminate due to patient well-being) -59: Separate and independent procedure performed same day -26: Professional component only
MODERATE SEDATION First 30 minutes (requires separate trained monitor): 99144 Each additional 15 minutes: 99145
DISCOGRAPHY Cervical/Thoracic (each disc): 62291 Supervision & interpretation — Cervical/Thoracic (each disc): 72285 Lumbar (each disc): 62290 Supervision & interpretation — Lumbar (each disc): 72295 Note: Fluoroscopy bundled — cannot bill separately.
VERTEBROPLASTY / KYPHOPLASTY Vertebroplasty — Cervicothoracic 1st level: 22510 Vertebroplasty — Lumbosacral 1st level: 22511 Vertebroplasty — Each additional level: +22512 Kyphoplasty — Thoracic 1st level: 22513 Kyphoplasty — Lumbar 1st level: 22514 Kyphoplasty — Each additional level: +22515 Note: Modifier -50 cannot be used for vertebroplasty or kyphoplasty. Global charge includes all imaging guidance and bone biopsy. Kyphoplasty has 10-day global period.
SPINAL CORD STIMULATOR (SCS) Trial Percutaneous electrode array implant (per lead): 63650 (10-day global) Permanent Implant — Percutaneous Percutaneous electrode array: 63650 (10-day global) Pulse generator insertion or replacement: 63685 (10-day global) Permanent Implant — Paddle Laminectomy for paddle electrode: 63655 (90-day global) Pulse generator insertion or replacement: 63685 (10-day global) Removal / Explant Percutaneous array removal: 63661 (10-day global) Paddle electrode removal: 63662 (90-day global) Pulse generator removal: 63688 (10-day global) Implanted neurostimulator electrodes (each lead): L8680
EMG & NERVE CONDUCTION STUDIES (NCS) NCS Counts (each sensory, motor w/ or w/o F-wave, or H-reflex = 1 study) 1-2 NCS: 95907 3-4 NCS: 95908 5-6 NCS: 95909 7-8 NCS: 95910 9-10 NCS: 95911 11-12 NCS: 95912 13+ NCS: 95913 Sensory NCS (each nerve): 95904 Motor NCS w/o F-wave (each): 95900 Motor NCS with F-wave (each): 95903 H-reflex — gastrocnemius/soleus: 95934 H-reflex — other: 95936 Blink reflex (orbicularis oculi): 95933 (once per study) EMG w/NCS — limited (4 or fewer muscles per extremity): 95885 EMG w/NCS — complete (5+ muscles, 3+ nerves or 4+ spinal levels): 95886 EMG w/o NCS — 1 extremity: 95860 / 2: 95861 / 3: 95863 / 4: 95864 Cranial nerve EMG unilateral: 95867 / bilateral: 95868 Muscle testing before study — extremity w/o hand: 95831 / hand: 95832 Note: Add modifier -26 if you do not own the EMG machine. EMG needles cannot be billed separately.
ACUPUNCTURE With electrical stimulation: 97813 Without electrical stimulation: 97810
PHYSICAL MODALITIES Diathermy (microwave): 97024 Heating pads / cold packs: 97010 Self-care / home management training: 97535 Therapeutic ultrasound: 97035 Traction: 97012 TENS: G0283
OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 body regions: 98925 3-4 body regions: 98926 5-6 body regions: 98927 7-8 body regions: 98928 9-10 body regions: 98929 Note: Use 98928 or less if OMT done with injection. Use 98927 or less if OMT done with epidural.
The CPT code for a T12-L1 interlaminar epidural steroid injection with imaging guidance is 62323
TRANSITION LEVEL CODING: T12-L1
For procedures at the thoracolumbar junction (T12-L1), the correct code depends on the specific structure and approach being treated. Here is the breakdown:
EPIDURAL STEROID INJECTION AT T12-L1
T12-L1 Interlaminar ESI — use LUMBAR code: 62323 T12-L1 Transforaminal ESI — use THORACIC code: 64479 (first level) T12-L1 Transforaminal ESI each additional level: 64480 Note: Transforaminal ESI at T12-L1 is coded as thoracic because the nerve root exiting at T12-L1 is a thoracic nerve (T12). The lumbar transforaminal codes (64483/64484) apply to L1 and below.
FACET INJECTIONS / MBB AT T12-L1
T12-L1 facet joint or MBB — use THORACIC code: 64490 (1st level) Each additional thoracic level: 64491, 64492 Note: The T12-L1 facet joint is considered a thoracic facet and is coded with thoracic facet codes (64490 series), not lumbar (64493 series). Note: If treating both T12-L1 (thoracic) and L1-L2 (lumbar) facets on the same day, bill 64490 for T12-L1 and 64493 for L1-L2 separately as they fall under different code families. Use modifier -59 to indicate distinct procedures.
RFA AT T12-L1
T12-L1 RFA — use THORACIC code: 64633 (1st joint) Each additional thoracic joint: 64634 Note: Same logic applies — T12-L1 is a thoracic joint for coding purposes.
QUICK REFERENCE SUMMARY
T12-L1 interlaminar ESI: 62323 (lumbar) T12-L1 transforaminal ESI: 64479 (thoracic) T12-L1 facet injection / MBB: 64490 (thoracic) T12-L1 RFA: 64633 (thoracic) L1-L2 and below facet / MBB: 64493 (lumbar) L1-L2 and below RFA: 64635 (lumbar)
T12-L1 disc herniation falls under the thoracolumbar category:
Disc herniation (Thoracolumbar T12-L1): M51.25 Radiculopathy 2/2 disc herniation (Thoracolumbar T12-L1): M51.15 Degenerative disc disease (Thoracolumbar T12-L1): M51.35
Note: T12-L1 is coded as thoracolumbar, not lumbar. The lumbar disc herniation codes (M51.26 / M51.27) apply to L1-L2 and below. Using the lumbar code for a T12-L1 disc herniation would be incorrect and could trigger a claim mismatch if paired with thoracic procedure codes such as 64479 or 64633.