Injection(s), anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint, cervical or thoracic; single level
62323
Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), interlaminar epidural or subarachnoid, lumbar or sacral
20610
Arthrocentesis, aspiration and/or injection; major joint or bursa
64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
99214
Office visit, established patient, moderate complexity
G89.x (pain, not elsewhere classified) codes are used when pain is the reason for the encounter, not an underlying condition. Do not use G89.x when an underlying diagnosis explains the pain.
Spinal injection CPT codes (62310–62327, 64479–64495) require documentation of the specific level, approach (interlaminar vs. transforaminal), and substance injected.
Z79.891 (long-term use of opiate analgesic) is a required additional code for all encounters where chronic opioid therapy is being managed.
Separate E&M services from interventional procedure codes using modifier -25 when both are documented on the same date.
What is the ICD-10 code for chronic low back pain?
Use M54.5 for low back pain. When the pain is radicular or associated with a disc condition, add the underlying diagnosis (M47.816, M51.16, M48.06). G89.29 (other chronic pain) may be added when pain chronicity is the focus of the encounter, not the underlying condition.
What CPT code is used for lumbar epidural steroid injection?
62323 covers interlaminar epidural injection at the lumbar/sacral level. 64483 covers the transforaminal approach. The distinction is based on needle trajectory documented in the operative note. Both require fluoroscopic or CT guidance, which is included in the code descriptor.
When is Z79.891 required?
Z79.891 (long-term use of opiate analgesic) should be added to all encounters where the physician is managing, renewing, or initiating chronic opioid therapy. It is a key code for PDMP compliance documentation and HCC risk adjustment.
What is the difference between G89.21 and G89.29?
G89.21 is chronic pain due to trauma (requires documented traumatic etiology). G89.29 is other chronic pain (used when the chronic nature is the clinical focus without a more specific code). Neither replaces the underlying diagnosis code — both are additional codes.
How does OmniMD support pain management documentation?
OmniMD’s Pain Management EHR includes procedure note templates for spinal injections, integrated PDMP querying, opioid treatment agreement tracking, and built-in urine drug screen result recording.
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