Melissa Harris CPC
Expert
Hello,
Can someone give me guidance in coding this procedure. I was thinking 64999 but it was done at 3 levels.
PROCEDURE: BILATERAL HARDWARE INJECTION
DIAGNOSIS: 722.52 - Intervertebral Disc Degeneration Lumbar, 724.8 - Back Symptoms Other, 722.83 - Postlaminectomy Syndrome Lumbar Region
INDICATIONS: Back pain
ANESTHESIA: Local/Conscious sedation
DESCRIPTION OF PROCEDURE: With written informed consent from the patient,risk and benefits were discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient was then brought to the operating room and with appropriate monitors in place, the patient was placed prone on the fluoroscopic table. The area of the low back on the Bilateral side was prepped with Betadine and draped in a sterile fashion. Utilizing fluoroscopic guidance, the pedicle was visualized at the junction of the transverse process where the patient had a previous surgery on oblique view. Skin wheals were raised at L2, L3 and L4 , using 2 mL of 1% Lidocaine at each. Two 22 gauge 3.5 inch spinal needles were passed through the skin wheals and directed toward these structures. Once bone was contacted at the levels, needle position was checked using both PA and cross table lateral view to be sure needle tip is in proper position. Once this was seen as satisfactory and after careful aspiration reveals no blood or CSF, a mixture of 5 mL of 0.25% Marcaine and 1 mL of 40mg/mL Kenalog and 6mL of 1% Lidocaine was injected through each of the needles. The needles were removed. The puncture wound was dressed. The patient was removed from the procedure table in stable condition and brought to the recovery area, having tolerated the procedure well.
Any help is greatly appreciated.
Melissa Harris, CPC
Can someone give me guidance in coding this procedure. I was thinking 64999 but it was done at 3 levels.
PROCEDURE: BILATERAL HARDWARE INJECTION
DIAGNOSIS: 722.52 - Intervertebral Disc Degeneration Lumbar, 724.8 - Back Symptoms Other, 722.83 - Postlaminectomy Syndrome Lumbar Region
INDICATIONS: Back pain
ANESTHESIA: Local/Conscious sedation
DESCRIPTION OF PROCEDURE: With written informed consent from the patient,risk and benefits were discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient was then brought to the operating room and with appropriate monitors in place, the patient was placed prone on the fluoroscopic table. The area of the low back on the Bilateral side was prepped with Betadine and draped in a sterile fashion. Utilizing fluoroscopic guidance, the pedicle was visualized at the junction of the transverse process where the patient had a previous surgery on oblique view. Skin wheals were raised at L2, L3 and L4 , using 2 mL of 1% Lidocaine at each. Two 22 gauge 3.5 inch spinal needles were passed through the skin wheals and directed toward these structures. Once bone was contacted at the levels, needle position was checked using both PA and cross table lateral view to be sure needle tip is in proper position. Once this was seen as satisfactory and after careful aspiration reveals no blood or CSF, a mixture of 5 mL of 0.25% Marcaine and 1 mL of 40mg/mL Kenalog and 6mL of 1% Lidocaine was injected through each of the needles. The needles were removed. The puncture wound was dressed. The patient was removed from the procedure table in stable condition and brought to the recovery area, having tolerated the procedure well.
Any help is greatly appreciated.
Melissa Harris, CPC