Outpatient Facility Coding Alert

Question: One of the pain management specialists submitted the following documentation:

"Utilizing fluoroscopic guidance in the vertical plane, we were able to appreciate the pedicle, bilateral L4-L5. The skin was anesthetized superficially and deeply utilizing lidocaine 1% without epinephrine or preservatives in a 25-gauge 1-1/2-inch needle. A 23-gauge spinal needle was advanced to the 6 o’ clock position of the pedicle entering the superior aspect of the neural foramen. In the oblique plane of view, the needle was moved into a more anterior position inferior to the pedicle. The needle was in the most superior aspect of the neural foramen avoiding the vascular structures inferior to the nerve root. Cross-table lateral view indicated the needle in the most superior aspect of the neural foramen."

He submitted charges for 64483-50, but I don’t understand how his notes confirm a bilateral procedure. Doesn’t the needle need to be inserted twice (once into the right intervertebral foramina and once into the left intervertebral foramina of the vertebra) to be considered bilateral? Or is there something in the documentation that I’m missing?

Minnesota Subscriber

Answer: The procedure details and documentation are somewhat weak to support that the provider performed the transforaminal epidural injection bilaterally, since the only reference was the fluoroscopic visualization of the bilateral L4-L5 pedicles.

Recommendation: Ask the physician to dictate an addendum to the procedure note, clarifying that the injection was first performed at the _________ (right or left) vertebral interspace and then repeated on the contralateral ________ (right or left) L4-L5 level. Then you can code the claim more accurately and will have supporting documentation.