Trudy Q
Contributor
My doctor did a procedure today that was very different and I am having trouble coding it as far as CPT codes I asked him if he felt this was a nerve block injection and he said he did not go to a nerve or joint he just injected where the pt states she is having pain near the rod in her spine It has to be near the L5-S1 because that is where she had surgery and hardware Below is a copy of his documentation of the procedure.
Does anyone have any ideas?? and if so could you explain why you choose that particular CPT code?
Needing Help in Paducah KY
TQ
Pre-Procedure Dx: Right low back pain
Post-Procedure Dx: Same
Procedure: Injection of superior aspect of right fusion rod for diagnostic purposes
Indications:
Ms. ??? has been treated for problems with right low back pain which Dr. McDonald felt may have been secondary to the length of a fusion rod which was making contact with the spine. He has requested a fluoroscopically guided diagnostic injection of this contact point to help determine the etiology of her pain.
She was taken through a conservative course of treatment without complete resolution of symptoms.
Injection therapy was then offered and after the risk and benefits of the procedure were
explained to the patient, we have agreed to proceed.
Procedure:
Mrs ???? was taken to the procedure room and placed in a prone position on the fluoroscopy table.
The above described area was identified utilizing AP fluoroscopy.
This area was marked cutaneously, prepped with betadine and draped with a sterile cloth.
1% lidocaine was then used to raise a small skin wheal beneath the cutaneous marking.
At that time AP fluoroscopy was used to direct a 20 gauge spinal needle to the superior aspect of the right rod where the patients complaints of pain were.
After careful aspiration, 2.5 cc of a 50/50 combination of 1% lidocaine and 0.5% marcaine mixed with 80 mgs. of methylprednisilone was injected without difficulties.
The patient tolerated the procedure well without complication and was discharged home in stable condition.
__________________
Does anyone have any ideas?? and if so could you explain why you choose that particular CPT code?
Needing Help in Paducah KY
TQ
Pre-Procedure Dx: Right low back pain
Post-Procedure Dx: Same
Procedure: Injection of superior aspect of right fusion rod for diagnostic purposes
Indications:
Ms. ??? has been treated for problems with right low back pain which Dr. McDonald felt may have been secondary to the length of a fusion rod which was making contact with the spine. He has requested a fluoroscopically guided diagnostic injection of this contact point to help determine the etiology of her pain.
She was taken through a conservative course of treatment without complete resolution of symptoms.
Injection therapy was then offered and after the risk and benefits of the procedure were
explained to the patient, we have agreed to proceed.
Procedure:
Mrs ???? was taken to the procedure room and placed in a prone position on the fluoroscopy table.
The above described area was identified utilizing AP fluoroscopy.
This area was marked cutaneously, prepped with betadine and draped with a sterile cloth.
1% lidocaine was then used to raise a small skin wheal beneath the cutaneous marking.
At that time AP fluoroscopy was used to direct a 20 gauge spinal needle to the superior aspect of the right rod where the patients complaints of pain were.
After careful aspiration, 2.5 cc of a 50/50 combination of 1% lidocaine and 0.5% marcaine mixed with 80 mgs. of methylprednisilone was injected without difficulties.
The patient tolerated the procedure well without complication and was discharged home in stable condition.
__________________
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