# Help with coding pain injection



## CONNIE214 (Mar 1, 2011)

Description of procedure:  The patient was taken to operating room and placed in the prone position. His low back was prepped with betadine and xylocaine 1% was infiltrated lateral to the midline at the l3-4 level, first on the right side. Under c-arm guidance, a 2-inch 25-gauge spinal needle was passed to  the l3-4 facet joint with no difficulty. No blood, csf or paresthesias was appreciated. I then injected 20 mg of depo-medrol and 0.5 ml of 0.5% mepivacaine. The needle was then redirected to the area of the medial branch nerve and the same injectant was injected. I then turned my attention to the left side where the procedure was repeated in an identical fashion. My question is: The dr has indicated this procedure to be 64483, 64484 bilaterally.  Is this correct?


----------



## btadlock1 (Mar 1, 2011)

Looks like 64483/50, 64484/50, to me.


----------



## dwaldman (Mar 2, 2011)

"Under c-arm guidance, a 2-inch 25-gauge spinal needle was passed to the l3-4 facet joint with no difficulty. No blood, csf or paresthesias was appreciated. I then injected 20 mg of depo-medrol and 0.5 ml of 0.5% mepivacaine"

Above is describing the Physician directing the needle towards the L3-L4 Facet Joint

"The needle was then redirected to the area of the medial branch nerve and the same injectant was injected."

Above is describing the Physician targeting the medial branch corresponding to L3-L4 facet joint 

As you can see in the coding example provided in AMA CPT Assistant, Paravertebral Facet Joint Blocks utilizing both an intraarticular joint block or Medial branch that innervate the same Facet level is only reported once. 

The reporting is 64493-50 due to the fact that there is treatment of a single level (ie L3-L4)
regardless of the number of injections it requires to block that level.



________________________________________________________________

From Encoder Pro Lay description of 64483

The physician injects anesthetic and/or steroid into the epidural space using a transforaminal approach. This approach is used primarily in the treatment of herniated discs and requires separately reportable fluoroscopic direction. The injection may be performed on a single or multiple lumbar or sacral level. Report 64483 for a single level, report 64484 for each additional level.

From Encoder Pro Lay description of 64493

The physician injects a diagnostic or therapeutic agent into a lumbar or sacral paravertebral facet joint or into the nerves that innervate the joint using fluoroscopic or CT guidance. The paravertebral facet joints, also called zygapophyseal or "Z" joints, consist of the bony surfaces between the vertebrae that articulate with each other. The injection may be performed on a single level or on multiple levels. Report 64493 for a single level, 64494 for a second level, and 64495 for the third and any additional levels. 
_____________________________________________________________________
CPT Assistant Sep 04

Example 3

The physician is performing medial branch lumbar facet nerve blocks as well as facet joint steroid injections using fluoroscopic localization (without contrast material). In performing this procedure, a needle is initially inserted within each facet joint. Then a steroidal agent is injected into each rightsided facet joints of L3-4, L4-5, L5-S1 and the needles are completely removed. Another set of needles are inserted, this time targeting the medial branch nerves supplying the aforementioned joints (L2, L3, L4, L5). An anesthetic agent is injected over each of these medial branch nerves and once again the needles are removed.

Rationale

In this example, the facet injection codes 64475 and 64476 represent unilateral procedures reported once for injection(s) at a specific level regardless of the number of needle(s) inserted or number of drug(s) injected. Therefore, for this specific intervention, the following codes should be reported:

Code 64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level, to describe the unilateral injections performed at L3-L4.

Code 64476, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure), to describe the unilateral injections performed at L4-L5.

Code 64476, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure, to describe the unilateral injections performed at L5-S1.

Code 76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction. The fluoroscopic localization for needle placement is described by code 76005 appended by modfier 26. The CPT professional component modifier 26 is appended. CPT code 76005 is intended to be reported once per spinal region (eg, cervical, lumbar) and not per level.


----------

