# 64483 or 64450?



## BFAITHFUL (Feb 1, 2013)

Can I use CPT code 64483, 64484x3 for diagnostic STEREOTACTIC injections at L5, S1, S2 and S3 lateral branches?  In accordance to current literature and anatomic studies, the innervation of sacroiliac joints is supplied by ipsilateral lateral branches of L5, S1, S2 and S3 nerve roots.

I actually think it sounds more like they are doing the lateral branch blocks that provide innervation to the SI joint as a diagnostic to see if patient's pain is originating from the SI joint, particularly with description of "3 o'clock" and "9 o'clock" positions. If in fact it was the lateral branches, then they are coded as 64450 x 4 rather than as transforaminal epidural injections right???? Thanks

After 9800 fluoroscope was brought in and AP view of lumbosacral spine was obtained.  The skin over the intersection of the articular process of L5 and sacral ala bilaterally was injected with 3cc of 1% lidocaine through a 25 gauge skin needle at each location and the skin wheals were raised.  3.5 inch 22 gauge spinal quincke needles were advanced through the skin negative and there was no paresthesia.  Each level was injected with 1cc of 0.25% bupivacaine.  At that point, visualization of opening of S1, S2 and S3 Foramina bilaterally was optimized via various degrees of cephalic and lateral tilt.  The skin over the 3 o'clock positions of the foramina at S1, S2 and S3 on the right and 9 o"clock poitions of the foramina of S1, S2, and S3 on the left were injected with 3cc of 1% lidocaine through a 25 gauge skin needle and skin wheals were raised.  3.5 inch 22 gauge spinal Quincke needles were advanced through the skin wheals and guided towards the appropriate location until they contacted the bone.  At that point, they were split into the rspective foramina.  Aspirations were negative and there were no paresthesias.  Each needle as injected with 0.5cc of Omnipaque 240.  The resulting dye distributioin confirmed the respective nerve root sleeves.  There was no evidence of intravascular dye.  At this point each level was injected with 1cc of 0.25% bupivacaine.  The needles were thenr emoved.


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## dwaldman (Feb 2, 2013)

The skin over the intersection of the articular process of L5 and sacral ala bilaterally was injected with 3cc of 1% lidocaine through a 25 gauge skin needle at each location and the skin wheals were raised. 3.5 inch 22 gauge spinal quincke needles were advanced through the skin negative and there was no paresthesia. 

I assume the above is for the lateral branch of L5 blocked bilaterally. With 64450-50

The skin over the 3 o'clock positions of the foramina at S1, S2 and S3 on the right and 9 o"clock poitions of the foramina of S1, S2, and S3 on the left were injected with 3cc of 1% lidocaine through a 25 gauge skin needle and skin wheals were raised. 3.5 inch 22 gauge spinal Quincke needles were advanced through the skin wheals and guided towards the appropriate location until they contacted the bone. At that point, they were split into the rspective foramina
This portion of the note was more difficult I tried to find an example of L5,S1,S2,S3 on the internet here is two examples 


With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern. Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area. All injected medications were preservative free. Sterile technique was used throughout the procedure.

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Teaching texts have suggested performing radiofrequency lesions at the superior lateral portion of the S2 and S3 foramina, at the medial branches of the higher dorsal rami in the lumbar region, at the sacral ala and SIJ junction, and along the posterior SIJ long axis. However, Vallejo asserts that there are no evidence-based studies to support such targets [22]. In the positive-outcome studies on radiofrequency neurotomy reviewed by Hansen, one used contiguous strip lesions (contiguous lesions produced between two probes) at the lateral dorsal foraminal aperture plus monopolar lesioning (lesion produced by one probe) at the L5 dorsal ramus, one targeted the sacral lateral branch using sensory-stimulation guiding, and one targeted the L4–L5 primary dorsal rami and S1–S3 lateral branches. The study by Vallejo, which achieved positive short-term but negative long-term results, used pulsed lesioning at the medial branch of L4, the posterior primary rami of L5, and the lateral branches of S1 and S2 [2]. The study by Ferrante, which achieved negative short-term and long-term results targeted the SIJ line, which Yin et al. [21] asserts is located laterally from where one can access the lateral branch nerves, since they are embedded within dense ligaments.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684948/

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The initial paragraph in your post, describes lateral branches of L5, S1, S2, S3, The procedure note describes bilateral injections at the 4 levels which would give you a total of of 8 injections or 64450-50 64450-50 51 64450-50 51 64450-50 51. I would provide to the provider the descriptor of 64483 and then explain the use of 64450, I believe he will end stating this was more SI joint dysfunction with 64450 than 64483/64484 codes.


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