Question: How should we code for aspiration of a synovial cyst of the facet joints?
Answer: CPT® does not include a code for aspiration of a synovial cyst at a facet joint. Therefore, you should report 64999 (Unlisted procedure, nervous system). If your provider uses fluoroscopic guidance during the procedure, report it with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid], including neurolytic agent destruction).
Filing tip: Be sure to clearly indicate in Box 19 of the 1500 form (or electronic equivalent) what specific service or procedure your provider completed. Your documentation should include any specific information about the procedure, such as an adequate definition or description of the nature, extent, and need for the procedure or service. Notes regarding the time, effort, and equipment necessary to provide the service should also be included.
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