# Help! Hardware Injection



## Melissa Harris CPC (Oct 22, 2014)

Hello,

Can someone give me guidance in coding this procedure.  I was thinking 64999 but it was done at 3 levels.  

PROCEDURE:   BILATERAL HARDWARE INJECTION

DIAGNOSIS:   722.52 - Intervertebral Disc Degeneration Lumbar, 724.8 - Back Symptoms Other, 722.83 - Postlaminectomy Syndrome Lumbar Region
INDICATIONS: Back pain 
ANESTHESIA:   Local/Conscious sedation     

DESCRIPTION OF PROCEDURE:   With written informed consent from the patient,risk and benefits were discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis.  Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse.  The patient was then brought to the operating room  and with appropriate monitors in place, the patient was placed prone on the fluoroscopic table.  The area of the low back on the Bilateral side was prepped with Betadine and draped in a sterile fashion.  Utilizing fluoroscopic guidance, the pedicle was visualized at the junction of the transverse process where the patient had a previous surgery  on oblique view.  Skin wheals were raised at L2, L3 and L4 , using 2 mL of 1% Lidocaine at each. Two 22 gauge 3.5 inch spinal needles were passed through the skin wheals and directed toward these structures.  Once bone was contacted at the levels, needle position was checked using both PA and cross table lateral view to be sure needle tip is in proper position.   Once this was seen as satisfactory and after careful aspiration reveals no blood or CSF, a mixture of 5 mL of 0.25% Marcaine and 1 mL of 40mg/mL Kenalog and 6mL of 1% Lidocaine  was injected through each of the needles.  The needles were removed.  The puncture wound was dressed.  The patient was removed from the procedure table in stable condition and brought to the recovery area, having tolerated the procedure well.


Any help is greatly appreciated.

Melissa Harris, CPC


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## dwaldman (Oct 22, 2014)

Below is from 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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