# Sympathetic Block via Lumbar Epidural space?



## drakena74 (Jul 18, 2014)

Please help with CPT!!  We coded 64520, but per Dr. stating did sympathetic block via epidural space (Lumbar Epidural Midline Sympathetic Block) and states he did a 62311. Can anyone help me with this? is it just the way he dictated the report? does he need to describe it in better detail?

Thank you!!

PREOPERATIVE DIAGNOSIS:
1.   Reflex sympathetic dystrophy lower extremities.
2.   Low back pain.

POSTOPERATIVE DIAGNOSIS:
1.   Reflex sympathetic dystrophy lower extremities.
2.   Low back pain.

PROCEDURE PERFORMED:
Lumbar epidural sympathetic block.

PROCEDURE IN DETAIL: 
I spoke to the patient in detail regarding the anesthetic plan of lumbar epidural sympathetic block. We spoke of the significant risks including, but not limited to, headache, bleeding, infection, nerve injury and reaction to the dye. The patient understands and agrees to proceed. She provided informed consent.

After getting proper informed consent, the patient was taken to the Operating Room and placed in the prone position on the Operating Room table,  back was sterilely prepped and draped with Betadine solution x 3.  Using fluoroscopic control, the L5-S1 interspace was identified.  Then using a 25-gauge needle and 0.25% Marcaine plain, the subcutaneous tissues and skin were anesthetized.  

Then an 18-gauge Tuohy needle was used to locate the epidural space using loss-of-resistance technique.  This was easily accomplished and a solution of five cc of Isovue 200 dye was instilled which gave an excellent epidurogram with spread of medication across the epidural space in both the AP and lateral dimensions.  

At this point, 10 cc of a solution that was comprised of 5 cc of 0.25% Marcaine plain and 5 cc of normal saline was administered, after aspiration was negative and test dose was negative for subarachnoid block or intravenous injection.  The needle was removed.  

The patient tolerated the procedure very well. She was discharged home in excellent condition after careful monitoring of he vital signs and neurological examination, which all remained stable for one hour.

The Braun tray was #61359284, the 0.25% Marcaine plain #6105391, normal saline #31214DK.

Interpretation of the films shows the needle to be properly placed at the L5-S1 interspace with contrast flow in both the AP and lateral views consistent with epidural placement. 

The patient did require IV sedation so with a registered nurse in attendance blood pressure, EKG and pulse oximetry were all monitored. The patient received 4 mg of IV versed and 100 mcg of fentanyl titrated to patient comfort. The patient stayed in the recovery room until she was neurologically intact. She was given 1 liter of fluid to maintain blood pressure.


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## dwaldman (Jul 21, 2014)

If the physician states what best describes the procedure is CPT 62311 then I would bill that code (62311). I believe the below documentation describes the location of the needle in the epidural space.

Using fluoroscopic control, the L5-S1 interspace was identified. Then using a 25-gauge needle and 0.25% Marcaine plain, the subcutaneous tissues and skin were anesthetized. 

Then an 18-gauge Tuohy needle was used to locate the epidural space using loss-of-resistance technique. This was easily accomplished and a solution of five cc of Isovue 200 dye was instilled which gave an excellent epidurogram with spread of medication across the epidural space in both the AP and lateral dimensions.


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## marvelh (Jul 22, 2014)

The local anesthetic injected epidurally only produced a block of the sympathetic nerve fibers, not the motor and/or sensory fibers.  I agree with the 62311 code.


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## drakena74 (Oct 23, 2015)

Thanks everyone! that's what we ended up coding & billing for.


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