# Transforaminal injections



## coderguy1939 (Jan 29, 2009)

On the op report under Procedures, the doctor states right-sided transforaminal injections at L3-L4, L4-L5, & L5-S1.  In the Procedure in Detail, the doctor does not include information as to which side he is injecting or at what levels.  He just refers to "each respective joint" and Depo-Medrol "was injected without complication at each of the respective levels".  Can this be coded as right-sided injections if the details are not included in the Procedure in Detail?  Thanks for your input.


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## magnolia1 (Jan 29, 2009)

I would request an amended procedure note.


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## jessieindiego (Feb 2, 2009)

But you said in the report he stated right-sided. I would say it's the right side. We code for left and right trans injections.


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