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Orthopedic Coding Alert

Reader Question:

Occiput-Atlas Is Level C1

Published on Wed Jan 01, 2003

Question: Our orthopedist indicated that he performed an occiput-atlas joint injection, but I can't find this in CPT. How should I code for it? Nevada Subscriber Answer: The occiput refers to the base of the skull, while the atlas is another name for the C1 vertebra. The occiput has convex facets, which roll on the joint surfaces of the cervical spine. Therefore, the orthopedist probably performed a cervical facet joint injection (64470, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level). Confirm this with the physician before submitting your claim, because the operative report lacked specificity. If the orthopedist injected additional levels (e.g., C2), append the add-on code +64472 (... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) to 64470. Do not append modifier -59 (Distinct procedural service) or -51 (Multiple procedures) to the add-on code because it inherently describes an additional, separate procedure.  
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