# Translaminar and Transforaminal procedures - HELP



## ireland2b (Mar 27, 2015)

I am hoping someone can help me. This is the documentation I was given. I have a lot of questions. 

The Left L4 foramen was identified in AP, lateral and oblique projections. In the oblique view, the entry point just inferior to the pedicle was identified and a mark was made on the skin.  The skin and subcutaneous tissues were anesthetized with 1% lidocaine via 27-gauge needle.  A 25-gauge 4.5inch spinal needle was then advanced via fluoroscopy in the oblique, lateral and AP projections, into the superior aspect of the L4 foramen on the left. Positioning was confirmed with 1ml of ISOVUE 200.  There was no blood, cerebrospinal fluid, or paresthesias.  At that point, a mixture of 6mg Decadron with 2ml of PFNS was slowly injected after negative aspiration. Needle was cleared with 0.5 cc of PF normal saline and removed atraumatically.    

Attention was then directed to the L5-S1 interspace.  The skin and subcutaneous tissues were anesthetized with 1% lidocaine via 27-gauge needle.  A 20-gauge, 6 inch, Weiss needle was then advanced via fluoroscopy into the epidural space in a left paramedian approach at L5-S1.  There was no blood, cerebrospinal fluid, or paresthesias. Needle placement confirmed wirh 1ml of ISOVUE 200. Then, 40mg Depomedrol mixed with 3ml PFNS was slowly injected after negative aspiration.  Needle cleared with 0.5cc 1% lidocaine and removed atraumatically.  

1. How do I know it's a translaminar or transforaminal procedure? Am I to know this by the location descriptors? 

2. What is Isovue200 and can that be coded? 

3. What are PFNS's? When I research I come up with a procedure and this context makes me feel it's a medication. 

As you can see I need a lot of guidance. Could you please help me code this? Thanks in advance!!!


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## dwaldman (Mar 29, 2015)

1. The L4-5 level describes:

"5inch spinal needle was then advanced via fluoroscopy in the oblique, lateral and AP projections, into the superior aspect of the L4 foramen on the left."

This would represent a transforminal epidural which can be determine by the needle being adavnaced into the L4 foramen with fluoroscopy. This fall under 64483.

The L4-S1 level describes:

" inch, Weiss needle was then advanced via fluoroscopy into the epidural space in a left paramedian approach at L5-S1."

This would fall under a interlaminar epidural with the description of the paramedian approach which falls under CPT 62311.

There is an NCCI coding edit between CPT 62311 and CPT 64483. They have designated CPT 64483 as the column two code and will bundle the payment into CPT 62311.  Although CPT 62311 has a lower RVU than CPT 64483, CPT 64483 falls as the column two code.

"Code 62311(column 1) has a CCI conflict with code 64483(column 2). A modifier is allowed to override this relationship. "

I am not sure on NCCI stance for this edit if they allow 59 at separate levels or if it is only applicable for separate encounters. 


2. Isovue 200 is a contrast used to assist with proper needle placement. It falls under the following HCPCS code. Typically it is reported where higher volumes is used such as with myelogram, but I couldn't find a current document stating it can not be billed for a single ml:

Q9966  Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml  

3. PFNS appears to represent preservative free normal saline


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