Injection Series: Part IV – (ESI) Epidural Steroidal Injection

woman's back with a fern on it

Photo Credit: Matheus Bertelli (Pexels)

An epidural steroid injection (ESI) is a medical procedure that delivers a steroid or corticosteroid medication into the epidural space—the fatty area surrounding the spinal cord that cushions the spinal cord and nerves. This procedure is commonly used to alleviate chronic pain conditions, including low back pain, neck pain, lumbar radicular pain, herniated discs, and spinal stenosis.

Epidural steroid injections can be categorized based on their location—cervical, thoracic, or lumbar—and the path of the needle, which includes interlaminar (between the laminae), transforaminal (through the foramen), and caudal (via the sacral hiatus) approaches.

Types of ESI:

  • Transforaminal – The needle is inserted slightly off the midline of the back to access the nerve canal.
  • Interlaminar – The needle entry site for accessing the spinal canal is located in the middle of the back. Anesthetic and steroid medications are administered by injection between the laminae of two adjacent vertebrae.
  • Caudal – The needle is inserted into the sacral hiatus, located above the tailbone, to access the lowest spinal nerves. This procedure is commonly utilized to alleviate widespread pain.

Top TPE Errors:

Medical necessity:
Documentation was lacking evidence to support local coverage (LCD) requirements.
Insufficient documentation: 
  • Documentation was not submitted in a timely manner to Medicare.
  • The submitted documentation did not substantiate the patient’s intolerance to non-invasive conservative care.

Essential elements in the TPE ESI documentation checklist include a clear record of the procedure’s indication and detailed procedural information, such as pre-and-post pain relief percentages, utilizing a consistent pain scale.

Finally, the LCD policy thoroughly outlines the reimbursement limitations concerning the recommended clinical criteria, frequency, and levels. Injections given without image guidance or ultrasound are typically not considered medically reasonable or necessary, unless there is a documented contraindication to contrast media, such as an allergy or pregnancy.

For more information, please see the links below for the TPE report, documentation checklist, and LCD (Limited Coverage Determination).

Resources:

Novitas TPE:  ESI and Checklist

ESI LCD Policy