Anesthesia Coding Alert

 Question: Our physician's dictation states, "At the junction of the L5 transverse process where it touches the sacrum because it is a transitional level, triamcinolone was injected." How should we code this?

Idaho Subscriber


 Answer: The dictation indicates the needle insertion site, but not the structure injected (ligament, tendon, muscle, etc.). Start by asking your provider the specific structure he injected.

 Lumbar transfer processes serve as attachment sites for many ligaments and the deep muscles of the back. Depending on the additional information your provider indicates, potential codes include 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) or 20551 (... single tendon origin/insertion).