Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed a therapeutic spinal opioid injection. How should I report this service?

Nebraska Subscriber

Answer: You’re going to need more informationin order to code this encounter. Go back and check the notes to see if you can answer these questions:

• What area of the spine did the surgeon inject?
• Did the surgeon use imaging guidance during the injection?

Then, you’ll have sufficient information to choose among the following codes for your surgeon’s injection:

• 62320 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance)
• 62321 (… with imaging guidance (ie, fluoroscopy or CT))
• 62322 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance)
• 62323 (… with imaging guidance (ie, fluoroscopy or CT)).