Wiki Injection - some insight on coding

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bda23054

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Could use some insight on coding this injection. The patient was having pain after hernia surgery, but no reocurrence found.
96372 isn't valid in outpatinet place of service. Not sure how to code this. Thanks.

DESCRIPTION OF PROCEDURE
Ultrasound is at the bedside to visualize the left inguinal canal with mesh visualized and the patient's abdominal wall thickness noted. The area is cleansed with ChloraPrep and just the lateral edge of the cicatrix over the inguinal canal a 1-1/2 inch, 25 gauge needle was used to infiltrate in a fan fashion 4 mL of Marcaine with epinephrine and 1 mL of Kenalog 40 mg mixture over the inguinal canal. Ultrasound was used to confirm this, it appeared to be in the right plane out of the intra-abdominal cavity and opposed subcutaneous tissue. Marcaine 5 more mL with epinephrine were infiltrated along more medially closer to the area that had some tenderness. The patient tolerated this well.

IMPRESSION/PLAN
The patient has left inguinal pain without evidence of recurring hernia, suspect chronic pain related to scar tissue, possibly nerve entrapment in the inguinal canal.
 
96372 is valid in the outpatient setting. However this does not read like an IM or SQ injection, looks like it was injected into the inguinal canal. you need a 338.2- dx code and a 905-909 code for late effect from surgery. The a different CPT code for the injection, suggest looking for something along the lines of abdominal wall injection.
 
I have been coding General Surgery for ten years and have always used 64425 as the closest thing for these injections. However, this time the coder from the facility side is questioning me that it's the incorrect code to use. I will go ahead and use it since that was my first thought. Thank you.
 
bda23054 said:
I have been coding General Surgery for ten years and have always used 64425 as the closest thing for these injections. However, this time the coder from the facility side is questioning me that it's the incorrect code to use. I will go ahead and use it since that was my first thought. Thank you.
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Just out of curiosity did this coder offer any other suggestion?
 
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