Wiki 64483/64484-1 or 2 levels?

[Emmalia]

Hi All,
I need some help clarifying the following report to decide if it should be coded as 1 level with 64483 or 2 levels with 64483, +64484. Any help would be appreciated.

"...After no evidence of dural puncture or intravascular uptake and with needle placement confirmed, injectate of 1 mL of dexamethasone 10 mg/mL and 1mL of lidocaine 1% was injected to each surrounding epidural space of the right L2 and L3 nerve roots and the patient was observed for adverse side effects..."

Thanks!

 

[dwaldman]

It appears it could represent 2 levels. What levels were on consent and was scheduled for? Does the note have a procedure heading with the levels addressed such as: L2-L3 and L3-L4. Also what side was this procedure was performed on?

If this particular physician will be performing more of these procedures that you will have bill for, now might be the time to go over what is needed to appropriately account for the services provided. Sometimes a simple conversation will have a positive impact on future documentation.

 

[dwaldman]

After re- reading it states the right side. But it seems there should be more description to support the approach that was used such as more detail of the location of the needle as it travels to the final target location for the release of the substance injected.