Wiki 20610 or another code?

[jdibble]

How would you code this injection for pain? The doctor billed it as 20610. This is the only thing he documented:

Notes: I've injected his lumbar spine with 2 cc of dexamethasone lidocaine and Marcaine, and this is given him symptomatic relief. We've adjusted his rolling walker to allow him to remain upright position when he ambulates. I think this will take pressure off his lumbar spine as well.

Would that be the correct code or is there a better code for an injection into the lumbar spine?

Thanks!

 

[maryalicecollins@gmail.co]

That is not the correct code for spinal injection. You will need additional information on the type of injection. ESI, trigger point, facet? There are several types of spinal injections that he could have performed.

 

[jdibble]

That is not the correct code for spinal injection. You will need additional information on the type of injection. ESI, trigger point, facet? There are several types of spinal injections that he could have performed.

That is the issue - the note I posted is all he documented. I am doing an audit on this physician and this has already been billed with this code. I am just trying to find a proper code to try and educate him on what he should be documenting and what he should have billled.

Thanks for your response!

 

[djolly]

I agree with MACollins. You cannot know what CPT should have been billed with the little documentation you have presented. There is some information about the medication Marcaine not being paid for by some when billed with the Dex. But you need to know the type of dex used too.