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CT guided INJECTION left SI joint injection and coccygeal injection
INDICATION: Left sacroiliitis, coccygeal pain
TECHNIQUE: The risks, benefits and alternative procedures were explained to the patient and informed consent was obtained. The patient was placed in the prone position and lower back cleaned and draped in a sterile fashion.
Under CT guidance, after the skin was marked for appropriate trajectory into the left SI joint inferior aspect and into the left para coccygeal space lower 2 elements, 1% lidocaine was used to anesthetize the soft tissues.
LEFT SI JOINT: A 22 gauge spinal needle was inserted under CT guidance at the inferior aspect synovial portion SI joint. A total of 40 mg of Depo-Medrol, 1 mL Marcaine 0.5% and 1 mL lidocaine 1% was delivered.
COCCYGEAL LEFT OF ARTICULATION OF TWO MOST INFERIOR ELEMENTS:
A 22 gauge spinal needle was inserted under CT guidance. A total of 40 mg of Depo-Medrol, 1 mL Marcaine 0.5% and 1 mL lidocaine 1% was delivered.
Needles were withdrawn. Sterile dressings were applied. The patient tolerated procedure well without postprocedure complication..
The patient received IV Versed and fentanyl given intravenously for adequate effective conscious sedation during the procedure for total of 30 minutes.
FINDINGS: Limited CT images demonstrates appropriate position of the needle within the left SI joint synovial space.
Limited CT images demonstrates appropriate position of the needle within the left articulation and to inferior most elements.
IMPRESSION: Successful CT guided left SI joint and coccygeal injection as described.
Thank you for referring patient Interventional Radiology for their procedure and allowing me to participate with you in their care.
How would you code this?
I know the SI Joint is 27096
but what about the coccygeal injection?
INDICATION: Left sacroiliitis, coccygeal pain
TECHNIQUE: The risks, benefits and alternative procedures were explained to the patient and informed consent was obtained. The patient was placed in the prone position and lower back cleaned and draped in a sterile fashion.
Under CT guidance, after the skin was marked for appropriate trajectory into the left SI joint inferior aspect and into the left para coccygeal space lower 2 elements, 1% lidocaine was used to anesthetize the soft tissues.
LEFT SI JOINT: A 22 gauge spinal needle was inserted under CT guidance at the inferior aspect synovial portion SI joint. A total of 40 mg of Depo-Medrol, 1 mL Marcaine 0.5% and 1 mL lidocaine 1% was delivered.
COCCYGEAL LEFT OF ARTICULATION OF TWO MOST INFERIOR ELEMENTS:
A 22 gauge spinal needle was inserted under CT guidance. A total of 40 mg of Depo-Medrol, 1 mL Marcaine 0.5% and 1 mL lidocaine 1% was delivered.
Needles were withdrawn. Sterile dressings were applied. The patient tolerated procedure well without postprocedure complication..
The patient received IV Versed and fentanyl given intravenously for adequate effective conscious sedation during the procedure for total of 30 minutes.
FINDINGS: Limited CT images demonstrates appropriate position of the needle within the left SI joint synovial space.
Limited CT images demonstrates appropriate position of the needle within the left articulation and to inferior most elements.
IMPRESSION: Successful CT guided left SI joint and coccygeal injection as described.
Thank you for referring patient Interventional Radiology for their procedure and allowing me to participate with you in their care.
How would you code this?
I know the SI Joint is 27096
but what about the coccygeal injection?