Orthopedic Coding Alert

YOU BE THE CODER ~ How Should We Bill Sacrococcygeal Injection?

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).

If the physician injects the joint, you should report 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]). 

Although some coders may recommend 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level), this is wrong because there is no facet joint in the sacrococcygeal region.

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