Neurosurgery Coding Alert

Question: Which 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 may administer injections to the sacrococcygeal region to treat conditions such as coccydynia (724.79, Disorders of coccyx; other).

Because your neurosurgeon 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 wrong 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]) instead.

Show these descriptors to your neurosurgeon and ask her which code more appropriately describes the procedure that she performed. Sometimes, the appropriate code descriptor does not exist, which should prompt use of  unlisted-procedure code 64999. 

If your physician had administered an epidural injection (meaning she 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]).