# 62282?



## kitkatcoder (Apr 13, 2010)

Hello,

I see that you are an expert at pain management and wanted to pick your brain.
Neurolytic solution was injected by cath but cath was removed…  so I did not use 62318 or 62311
Would it be appropriate to use 62282 on case..Office and I are going back and forth on this and they are wanting to use 62318…Any help I would greatly appreciate.


PREOPERATIVE DIAGNOSES:  
1.     Low back pain.
2.     Lumbar radicular pain.

POSTOPERATIVE DIAGNOSES:  
1.     Low back pain.
2.     Lumbar radicular pain.

OPERATIONS PERFORMED:  
1.     Fluoroscopic evaluation of lumbar spine.
2.     Diagnostic lumbar epidurogram.
3.     Anesthetic injection per epidural catheter.
4.     Steroid injection per epidural catheter.
5.     Injection of hypertonic saline.

ANESTHESIA:  MAC with IV sedation.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

INDICATIONS:   is a 75-year-old male who has got significant pain in his low back region and pain in his left lower extremity.  He has undergone conservative measures recently with persistent pain.  The risks and benefits of the procedure were explained to the patient.  The patient agrees to proceed with the procedure.

DESCRIPTION OF PROCEDURE:  The patient was taken to the OR #3 and placed in a prone position.  Pressure points were checked and padded.  Monitoring was provided, which included EKG, blood pressure, and pulse oximetry.

Lumbosacral region was prepped and draped in a sterile fashion.  Sacral hiatus was identified in lateral fluoroscopic view.  Left paramedian insertion site was marked.  After adequate IV sedation, the skin over the insertion site was infiltrated with 1% lidocaine.

 
Next, a 16-gauge RK needle was advanced under fluoroscopic direction until it passed in the sacral hiatus.  The needle-tip position was confirmed via AP and lateral fluoroscopic views.  Next, an epidural catheter was advanced in a ventral-to-cephalad direction and placed at the mid L5 vertebral body region at the midline.  The catheter was confirmed via AP and lateral fluoroscopic views.  Next, 10 mL of Omnipaque contrast was used to perform diagnostic lumbar epidurogram.  There was very minimal spread of the dye in a cephalad direction.  With additional fluid injected, there was some flow of dye to the L4-L5 level and none above that level.  Next, 3 mL of 0.25% Marcaine was given as a test dose.  After a few minutes, there was no evidence of intrathecal, intravascular, or subdural spread of local anesthetic.  Next, 7 mL of 0.25% Marcaine mixed with 40 mg of Kenalog was injected slowly with frequent negative aspiration.  The patient tolerated the procedure well with stable vital signs followed by injection of 7 mL of 10% sodium chloride.  Catheter was then flushed with 1 mL of 1% lidocaine.  The catheter and needle were then withdrawn with the tip intact.  Sterile Band-Aid was applied at the catheter insertion site.  The patient was transported to the PACU in stable condition.  After few minutes in the recovery room, vital signs were stable.  There was no evidence of any motor blockade to lower extremities.  The patient remained in the monitored setting prior to discharge to home.


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## dwaldman (Apr 14, 2010)

I haven't seen anything in CPT assistant stating if you use a catheter and the mediciation is "slowly injected" it is considered best represented with an infusion code 62318/62319. The procedure does not seem similiar to a standard epidural via a single injection. I was unsure about sodium chloride and kenalog this didn't look like a neurolytic(62282). I could not find anything on sodium chloride. Where you leaning towards 62319?


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## dwaldman (Apr 14, 2010)

Sorry I found sodium chloride under hypertonic saline, the procedure you are listing is similiar to this day 2 lysis of epidural adhesions procedure note I found minus the hyaluronidase.




"Pt in OR under prone position --- betadine prep done. Surgical timeout done. After negative aspiration 3 cc of Isovue 200 was injected thro the cathether under flouro showing the epidural catheter is in the epidural space. 10cc of 0.5% Lidocaine + Kenalog 40 mg solution was injected followed by Hyaluronidase(Vitresse) 200 units . After 3 minutes -- 10 ml of 10% NACL was injected slowly in 10 min . Epidural catheter was removed intact. Pt was monitored in RR for 45 min before discharging to her hospital room Pt tolerated the procedure well."


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## rkmcoder (Apr 14, 2010)

(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

There was no neurolytic substance injected, so 62282 is not your code, and there was no lysis of adhesions mentioned, so 62264 is not your code.  I would code this as 62319.  Others will indicate that 62319 requires leaving the catheter in for a period of time, and will want to use code 62311.  You decide about that.  AND, the description indicates that the dye was used for needle localization and not for diagnostic purposes, so do not code an epidurogram, use the fluoro code 77003.  If, though, there are hardcopy images in multiple planes documenting the flow of contrast, and a separate formal radiologic report available, then code 72275.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## dwaldman (Apr 14, 2010)

I wasn't able to talk a physician about this but I talked the pharmcist. She stated that NaCL, sodium choloride, Hypertonic saline are the same thing. I asked her if this substance that is used to perform the "lysis" of the adhesions and she said yes. I asked her if she believe it was a neurolytic and she said no. I noticed that Lysis of Epidural Adhesions code 62264/62263 has (eg hypertonic saline,enzyme) whereas 62282 has (eg alchol , phenol, iced saline solutions) I asked her if hypertonic saline was the same thing as iced saline solutions. She seemed unsure about that.

I was looking at the below link and trying to determine if they were considering hypertonic saline a neurolytic.

http://www.coccyx.org/medabs/rowe.htm


Hypertonic saline
The use of hypertonic saline by intrathecal injection to treat intractable pain was first reported by Hitchcock in 1967. The most commonly used solution is the 10 percent aqueous solution and is available as a pharmaceutical preparation. Its mechanism of neurolysis is not well elaborated. It causes severe pain on injection and local anesthetic is first injected before the saline solution. When administered intrathecally, hypertonic saline can cause an increase in the intracranial pressure, increase in blood pressure, heart rate and respiratory rate.


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## RebeccaWoodward* (Apr 14, 2010)

I just have to say that I'm intrigued with the dialogue that DWaldman and Richard are having in this thread and  other threads.  I'm learning many new things just reading their responses...

Thanks to you both-


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## kitkatcoder (Apr 14, 2010)

But it does not mention anything about adhesions so would it really be appropriate to use 62264...

and 62311 does say (opiod, steroid, other solution) so would it fit to use 62311?


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## rkmcoder (Apr 14, 2010)

(These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

Kitkatcoder - Please see my post above.  Both of these issues were discussed in that post.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## dwaldman (Apr 14, 2010)

What about talking to the physician and have him help rule out what was performed Here are the lay descriptions from encoder that is if you have contact with this particular physician.

62319
The patient is placed in the sitting or lateral decubitus position for the physician to insert a catheter into the vertebral interspace of the lumbar or sacral region for continuous or intermittent infusion of material. The site to be entered is sterilized, local anesthesia is administered and the infusion catheter is inserted. Contrast media may be injected to confirm proper catheter placement. The physician provides continuous infusion or intermittent bolus injection of solution to provide a therapeutic or diagnostic outcome. The solution is injected into the epidural or subarachnoid space. With the procedure complete the needle is removed and the wound is dressed.

62282
This procedure is performed to destroy nerve tissue or adhesions. The patient is placed in a spinal tap position. The site is sterilized, and the needle is inserted under fluoroscopic guidance. The needle is placed at the proper level and the neurolytic substance is administered. Once the injection/infusion is completed, the needle is removed and the wound dressed. Report 62280 if the substance is administered to the subarachnoid level. Report 62281 if the needle is inserted in the epidural region of a cervical or thoracic level. Report 62282 if the needle is inserted in the epidural region of a lumbar or sacral (caudal) level.

62264
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. Separately reportable contrast media with fluoroscopy may be injected to confirm proper needle placement and to identify epidural adhesions. The 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.


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