Neurosurgery Coding Alert

Question: I have a procedure report that states, "Injection of posterior lumbar hardware for purposes of diagnosis of pain." The physician injected 5 cc of Marcaine to the lumbar spine, on both sides of the patient's spinal hardware. How should I code for this procedure?

Iowa Subscriber

Answer: CPT does not include a specific code describing the injection of anesthetic agent to the paraspinal region where spinal instrumentation is located. Because of this, your best options are 22899 (Unlisted procedure, spine) or 64999 (Unlisted procedure, nervous system). Discuss the case with your physician to determine which code is more appropriate.

Patients sometimes have continuous pain after spinal fusion that your physician will try to diagnose and treat. Hardware removal is a major procedure, so the surgeon might assess the problem less invasively before subjecting the patient to surgery -- such as performing a diagnostic injection to learn if the hardware is the source of the patient's pain, as your physician did.

-- Technical and coding guidance for You Be the Coder and Reader Questions provided by Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.