# Cyst aspiration & esi



## Coder.Melisa (Feb 13, 2013)

I need a little help with an Op Report and I am not sure if my doctor can be paid for all procedures he has performed as I beleive they are all included. Any feed back and Help would be greatly apprectiated, Thank you for the replies. 

The right L4-5 synovial cyst was aspirated. Methyprednisolone 40 mg was injected into the right L4-5 transframinal epidural space in divided doses.

The fluoroscopy camera was repisitioned to indentify the right L5-S1 interlaminar space. The skin above the region was infiltrated with Xlocaine using a 27-gauge needle. A Weiss needle was andvanced under fluoroscopice guidance to the rigth L5-S1 epidural space using a loss-of-resistance technique. Proper need placement was confirmed using myltiple fluoroscopic views AP, Oblique, and lateral positions, and 2 cc of Isovue-200 contrast was placed. This showed an appropriate epidural spread pattern. There was no vascular uptake. Methyprednisolone 40 mg was administered in divided doses into the epidural space. The need was withdrawn and sterile dressing applied. 

I know that since the Cyst Aspiration and the first ESI were done on the same area the L4-5, they are bundled. Would I be able to code ESI for the L5-S1 and if so what code would I use.


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## dwaldman (Feb 13, 2013)

Might want to look at if it was necessary to aspirate the cyst in order to access the area to perform the epidural, if so I would believe it would be inclusive.

If not they could be potentially separately reported since there is nothing that states they are inclusive at the same level, but since the cyst aspiration is unlisted, I would believe there needs to be more description of this procedure for the carrier to be able to gage how much extra work this took for pricing and for considering extra payment. If you have not seen the below I copy and pasted it, from AMA CPT Assistant.

July 2011 page 17

Frequently Asked Questions:Surgery: Nervous System

Question: What is the correct coding for aspiration of a synovial cyst of the facet joints? 

Answer: There is no specific code for the insufflation and aspiration of a synovial cyst at a facet joint. Therefore, code 64999, Unlisted procedure, nervous system, may be reported to represent this procedure. If fluoroscopic guidance is used, it may be additionally reported with code 77003, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction. 

Unlisted codes do not describe a specific procedure or service, so when using these codes, it may be necessary to submit supporting documentation (eg, an operative report or office notes) when filing the claim. This report is included to identify the specific information regarding the procedure(s) identified by the unlisted code. Relevant information should include an adequate definition or description of the nature, extent, and need for the procedure or service, as well as the time, effort, and equipment necessary to provide the service.


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## dwaldman (Feb 13, 2013)

You could point out in the cover letter that a transforminal epidural 64483 and facet block 64493 are not a code pair within NCCI. And that the work represented for the synovial cyst aspiration could be valued at 64493. I think the fact that they are not bundled is something to consider in the determination if the services are inclusive or not.


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## Coder.Melisa (Feb 18, 2013)

Thank you for all the help and the great feedback it is greatly appreciated.


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