Wiki coding for spinal steroid injections

[Jro]

I'm learning coding for ortho procedures and have a question. My physician is documenting his note like this:

"Left C4 and C5 transforaminal epidural steroid injection."

In the body of the procedure note he says:

".....spinal needle was guided successfully into the left C4 and C5 neuroforaminal space employing an anterior lateral approach. And, ".....under fluoroscopy, opacified the spinal nerve and ........"

My question has to do with the level(s) I need to code. Would you consider this one level (C4/5)? Or, 2 levels (C4 and C5)? And, if 2 levels, do I need to see movement of the needle to the 2nd level documented --- or, a 2nd nerve documented? Thanks for helping this newbie!

 

[jmcpolin]

The foramen is between each vertebral body so C4-C5 would be one injection, yes you would need a second needle placement to bill an additional level.

 

[Jro]

Thank you for helping! Articles on the internet have just confused me.
Again, thanks.

 

[Jro]

Oooops, also wanted to ask about the lumbar/sacrum......it's the same procedure -- I mean, tranformaninal epidura steroid injection -- but, it's for the L5 and S1 area. He says:

"....spinal needle was guided into the right L5 and S1 neural foraminal space...." and then,

" ......opacified the spinal nerve and ........" Again, no other mention of the needle moved to another area or another nerve mentioned. I believe that this should also be 1 level? Thanks.........