Injection Series: Part IV – (ESI) Epidural Steroidal Injection
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 injection procedure commonly alleviates chronic pain conditions, including low back pain, neck pain, lumbar radicular pain, herniated discs, and spinal stenosis.
Clinicians categorize epidural steroid injections by location (cervical, thoracic, or lumbar) and by needle path, including interlaminar (between the laminae), transforaminal (through the foramen), and caudal (via the sacral hiatus) approaches.
Types of ESI:
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Transforaminal – The provider inserts the needle slightly off the midline of the back to access the nerve canal.
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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.
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Caudal – The needle is inserted into the sacral hiatus, located above the tailbone, to access the lowest spinal nerves. This procedure is commonly performed to alleviate widespread pain.
Top TPE Errors:
- Medicare did not receive provider documentation in a timely manner.
- The submitted documentation did not substantiate the patient’s intolerance to non-invasive conservative care.
Specifically, 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 clearly outlines reimbursement limitations related to clinical criteria, frequency, and service levels. Medicare generally considers injections without image guidance or ultrasound not medically reasonable or necessary unless the record documents a contraindication to contrast media, such as allergy or pregnancy.
For more detailed 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