# Hardware Injection



## Melissa Harris CPC (Aug 12, 2015)

Hello,

I am a little confused and hope that someone can help me.

My provider injected hardware at right SI joint, left T10 and right and left T11 for a Medicare patient.  Do I bill this 64999 4 times separately?
Here is the note

PROCEDURE:      RIGHT HARDWARE  INJECTION




DESCRIPTION OF PROCEDURE: After written informed consent was obtained from the patient and benefits and risks discussed, including, pain relief, infection, bone and nerve damage, the patient was placed prone on the fluoroscopic operating room table with the appropriate monitors in place.  The area of the Left and Right mid to low back is prepped with Betadine and draped in sterile fashion. Utilizing fluoroscopic guidance the patient's spinal fusion hardware and a sacro illiac joint screw is visualized and skin wheals were raised using 1-3 cc of 1% lidocaine over the Right sacro illiac joint pedicle screw, the left T10 hardware and left and right T11 hardware.
At this point two 25 gauge 3-1/2 inch spinal needles with curved tips was passed through the skin wheals and advanced to the screw heads.  Once contact is made after careful aspiration revealed no blood or CSF,  2 cc of a mixture of  4mL of 0.25% Marcaine, 2mL of 1% Lidocaine and 2 mL of 40 mg/mL of Kenalog was injected through each of the 2 needles.
The patient experienced concordant pain at this point.  The needles were removed and the puncture wounds dressed.  The patient was returned to the recovery area in stable condition with noticeable pain relief.

Fluoroscopic Time:  0-1 minute

PRE-OPERATIVE PAIN SCORE: 5/10
POST-OPERATIVE PAIN SCORE: 2/10
VITALS DURING PROCEDURE:    O2Sat:98%			Heart rate:85

Any help is greatly appreciated.

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management


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## dwaldman (Aug 12, 2015)

I would believe you would report one unit and then provide description of what procedures were performed. I couldn't find it, but I believe there is a CPT Assistant that states you only use one unit if all the procedures that are performed are unlisted and all of those procedure fall under the same unlisted code.


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