Anesthesia Coding Alert

Question: What code should I report when the physician administers a steroid injection in the patient's sacrococcygeal region because of bone pain? He said it is not a lumbar epidural.

Colorado Subscriber

Answer: Physicians administer injections to the sacrococcygeal region to treat coccydynia (724.79, Disorders of coccyx; other). A good example of when this happens is when the patient is an avid bicyclist.
 
Because your physician did not administer an epidural, some coders recommend reporting 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) for this procedure. Other coders say this is incorrect because your physician did not inject the facet joint. These coders opt for 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]).
 
If your physician had administered an epidural injection (meaning he reached the dura), you would report 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).