# Pain management injection



## Trudy Q (Aug 20, 2013)

My doctor did a procedure today that was very different and I am having trouble coding it as far as CPT codes I asked him if he felt this was a nerve block injection and he said he did not go to a nerve or joint he just injected where the pt states she is having pain near the rod in her spine It has to be near the L5-S1 because that is where she had surgery and hardware Below is a copy of his documentation of the procedure.
Does anyone have any ideas?? and if so could you explain why you choose that particular CPT code?
Needing Help in Paducah KY  
TQ

Pre-Procedure Dx: Right low back pain
Post-Procedure Dx: Same
Procedure: Injection of superior aspect of right fusion rod for diagnostic purposes

Indications:
Ms. ??? has been treated for problems with right low back pain which Dr. McDonald felt may have been secondary to the length of a fusion rod which was making contact with the spine. He has requested a fluoroscopically guided diagnostic injection of this contact point to help determine the etiology of her pain.
She was taken through a conservative course of treatment without complete resolution of symptoms.
Injection therapy was then offered and after the risk and benefits of the procedure were
explained to the patient, we have agreed to proceed.

Procedure:
Mrs ???? was taken to the procedure room and placed in a prone position on the fluoroscopy table.
The above described area was identified utilizing AP fluoroscopy.
This area was marked cutaneously, prepped with betadine and draped with a sterile cloth.
1% lidocaine was then used to raise a small skin wheal beneath the cutaneous marking.
At that time AP fluoroscopy was used to direct a 20 gauge spinal needle to the superior aspect of the right rod where the patients complaints of pain were.
After careful aspiration, 2.5 cc of a 50/50 combination of 1% lidocaine and 0.5% marcaine mixed with 80 mgs. of methylprednisilone was injected without difficulties.
The patient tolerated the procedure well without complication and was discharged home in stable condition. 
__________________


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## dwaldman (Aug 21, 2013)

ICD-9 724.2 Lumbago/Low back pain
ICD-9 V45.89 Postprocedure status

ICD-10 M54.5 Low back pain
ICD-10 Z98.89 Other specified postprocedural states 

CPT 
64999

Resources:
AAPC ICD-10 code translator

AMA CPT Assistant
May 2012 page 14

Frequently Asked Questions:Surgery: Nervous System

Question: What code(s) may be reported for injection of 0.5% Marcaine and 80 mg of Depo-Medrol to existing spinal hardware (eg, pedicle screws) at L4, L5, and S1 bilaterally? May code 64483 be reported? 

Answer: No. Code 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level, represents transforaminal epidural nerve root injection performed in the lumbar region. There is no specific CPT code for the injection of spinal hardware. CPT code 64999, Unlisted procedure, nervous system, would be most appropriate to describe the injections for pain performed outside the foramen, as indicated in the clinical scenario provided in this inquiry. Although three spinal level (L4, L5, S1 bilaterally) injections were performed, code 64999 should be reported only once to represent the multiple injections.


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## mitchellde (Aug 22, 2013)

I agree with dwaldman except I would add and list first, the 338.1- code for acute postoperative pain (G89.- ICD-10)


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## Trudy Q (Sep 2, 2013)

Dear True Blue:

Your response is exactly my thinking and has source material to back it up!!!  Thanks so much I appreciate your response.
TQ


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