# Please advise



## NESmith (Mar 28, 2014)

Description of the Procedure
With the patient having had an IV started and all routine monitoring intact, patient was placed in the prone position. A sterile meticulous prep of the entire lumbosacral area was performed and sterile draping was placed. Under fluoroscopic visualization, the Sacral hiatus was delineated and a 25-gauge needle was used to infiltrate the skin with 1% local lidocaine. A 18-gauge RACZ needle was then used and placed on the sacral canal using direct fluoroscopic visualization to access the peidural space. There were no patient complaints of paresthesia and hthere was no evidence of blood or CSF. At this point, an injection of Ominpaque 300 2 cc non-ionic contrast dye was perfomred and contrast was seen to extend through the epidural space.
For the purpose of diagnosis and interpretation, hard film copies were taken for the patient's record.
A RACZ cathether is then advanced in the epidural space. Adhesions were encountered by the catheter at the surgical site L5 S1 fusion area. Injection of 1 cc of Isovue 300 shows poor spread of the dye in the epidural space. These adhesions were broken down by hydrodisscetion with NSS and the mechanical action of the catheter. This was repeated until the spread of the radioopaque was noted to be homogeneous and adequate. 
At this point, we prepared a solution containing 4 cc of preservative-free normal saline and 1 cc Kenalog(traimcinolene) 40 mg per ml was injected after aspirating for blood or CSF. The needle was subsequently withdrawn. All injection sities were covered with sterile dressings.

Does this represent CPT code 62264 or 62311?
Thank you as always for your help.
Reading to many different reports and trying to decide what is correct.


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## Melissa Harris CPC (Mar 31, 2014)

You would bill the 62264 since there is lysis of the adhesions.

Melissa


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## NESmith (Mar 31, 2014)

Thank You Melissa for your response but we have a billing company stating the lysis of adhesions is inclusive to the injection and we should be billing the 62311.
Please give me your thoughts on this issues.


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## Melissa Harris CPC (Mar 31, 2014)

According to CPT 2014 62264 os Percutaneous lysis of epidural adhesions using solution injection or mechanical means including radiologic localization - one day



I don't understand what they mean included with the injection??


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## dwaldman (Apr 1, 2014)

Epidural adhesions are lysed percutaneously by an injection, such as hypertonic saline or an enzyme solution, or by mechanical means. The patient is placed in the sitting or lateral decubitus position for insertion of a needle into a vertebral interspace. The site to be entered is sterilized, local anesthesia is administered, and the needle is inserted physician injects the adhesiolytic solution or performs mechanical adhesion destruction, such as with a catheter, to lyse epidural adhesions. The needle and/or catheter is removed and the wound is dressed. Report 62263 for multiple adhesiolysis sessions on two or more days and 62264 for multiple adhesiolysis sessions occurring only on one day. 

Above is the lay descriptor from Optum Encoder.
From an NCCI perspective, see below

Code 62311 is a component of Column 1 code 62264 and cannot be billed using any modifier. 

This indicates that the code pair involves 62264 as the column one code and 62311 as the column 2 code. The bundling edit makes 62311 an included component and separately billable when performed with 62264.


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## dwaldman (Apr 1, 2014)

AMA CPT Changes 2000
"Code 62263 is a new code describing a relatively new procedure not previously described by CPT. Code 62263 describes a percutaneous epidural catheter-based treatment involving targeted injection of various substances (including hypertonic saline, steroid, anesthetic, and mechanical adhesion lysis) coupled with epidural injection of contrast to define areas of scarring around nerve roots and/or spinal nerves as well as to define swollen nerves that might indicate moderate to severe inflammation in the nerves per se."

Above describes when the lysis of epidural adhesions code first was introduced. As seen above the injection can involve various of substances which commonly in addition to the neurolytic agent or mechanical lysis, is the injection of anesthesic/steroid. 

The note you have provided below excert clearly represents a lysis of epidural adhesions. This service should be reported by CPT 62264 for a one day treatment

"A 18-gauge RACZ needle was then used and placed on the sacral canal using direct fluoroscopic visualization to access the peidural space. There were no patient complaints of paresthesia and hthere was no evidence of blood or CSF. At this point, an injection of Ominpaque 300 2 cc non-ionic contrast dye was perfomred and contrast was seen to extend through the epidural space.
For the purpose of diagnosis and interpretation, hard film copies were taken for the patient's record.
A RACZ cathether is then advanced in the epidural space. Adhesions were encountered by the catheter at the surgical site L5 S1 fusion area. Injection of 1 cc of Isovue 300 shows poor spread of the dye in the epidural space. These adhesions were broken down by hydrodisscetion with NSS and the mechanical action of the catheter. This was repeated until the spread of the radioopaque was noted to be homogeneous and adequate"

Below is AMA CPT Changes 2003, when CPT 62264 was introduced. The procedure described below:

Description of Procedure (62264)


After the appropriate preparation and consent, the patient is taken to the operating room or a sterile procedure room where preparation is carried out with povidone-iodine prep. Draping is carried out to cover the patient, extending into the midthoracic or cervical region, even if the procedure is performed in the lumbosacral region. Appropriate monitoring is carried out, with monitoring of BP and pulse and pulse oximetry. Sedation is slowly administered. The fluoroscope is adjusted over the lumbosacral region for AP and lateral views. A physician, scrubbed and in sterile gown and gloves, infiltrates the area for needle insertion with local anesthetic. Following this, an RK needle is introduced into the epidural space under fluoroscopic utilization. Once the needle placement is confirmed to be in the epidural space, a lumbar epidurogram is carried out utilizing approximately 2 to 5 mL of contrast. Finding the filling defects by examining the contrast flow into the nerve roots is the purpose of the epidurogram. Intravascular or subarachnoid placement of the needle or contrast is avoided; if such malpositioning occurs, the needle is repositioned. After appropriate determination of epidurography, a Racz catheter, which is a spring-guided, reinforced catheter, is slowly passed through the RK needle to the area of the filling defect or the site of pathology determined by MRI, CT, or patient symptoms. Following the positioning of the catheter into the appropriate area, adhesiolysis is carried out by mechanical means. After completion of the adhesiolysis, a repeat epidurogram is carried out by additional injection of contrast. If appropriate adhesiolysis is completed, nerve root filling as well as epidural filling will be noted. At this time, variable doses of local anesthetic and steroid are injected. Five to 10 mL of 2% lidocaine hydrochloride or 5 to 10 mL of 0.25% bupivacaine are used for the local anesthetic. Additionally, hyaluronidase may be injected at this time. A steroid is injected in the operating room or recovery room. Following completion of the injection, the catheter is taped utilizing bio-occlusive dressing; and the patient is turned to the supine position and transferred to the recovery room.


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