babychristian05
New
Question....
I'm going round and round with this. If the doctor reports
LEFT Selective nerve root block/Transforaminal epidural steroid injection
Cervical/Thoracic C6 and C7
Description of Procedure :
The patient was registered to Spine Center of Excellence. The patient was greeted and any pre-procedure questions were
addressed. Informed consent was obtained. If sedation was preformed, intravenous access was established to use for patient
safety. The patient was then taken to the procedure suite where they were positioned in a comfortable position with the
assistance of a nurse. Appropriate monitoring was applied and utilized throughout the procedure. The fluoroscope was then
utilized to visualize the appropriate landmarks for injection.
The cervical region was examined and prepped and drapped in the usual sterile fashion. Using image intensifier in AP, oblique
and lateral projections landmarks of the intended neuroforamina was mapped out.
Next, a 25 gauge Quincke needle was advanced and negotiated to the posterior margin of the neuroforamen and verified on
multiplanar imaging. Aspiration was negative for blood, air, and cerebral spinal fluid. No paresthesias were provoked with
needle placement.
Injection of of contrast material demonstrated foraminal filling, perineural highlight of the nerve root. There was no evidence for
subdural, subarachnoid, or intravascular uptake.
Next, a solution containing lidocaine and Decadron was incrementally injected. The needle was flushed and removed.
The procedure was repeated for the other listed level(s) (If LISTED). Decadron 10mg was dived between all injections.
Fluoroscopic images were saved and transferred to PACS. The patient was transferred to the PACU and tolerated the
procedure well with no complications.
Would this be considered one level or two?
From everything I can find it should be listed example c5/6 for one level and say c6/7 for the next level no matter how many injections.
The way I read this it would only be cpt 64479-LT. Is this correct? Can someone help me with some guidance on this?
I'm going round and round with this. If the doctor reports
LEFT Selective nerve root block/Transforaminal epidural steroid injection
Cervical/Thoracic C6 and C7
Description of Procedure :
The patient was registered to Spine Center of Excellence. The patient was greeted and any pre-procedure questions were
addressed. Informed consent was obtained. If sedation was preformed, intravenous access was established to use for patient
safety. The patient was then taken to the procedure suite where they were positioned in a comfortable position with the
assistance of a nurse. Appropriate monitoring was applied and utilized throughout the procedure. The fluoroscope was then
utilized to visualize the appropriate landmarks for injection.
The cervical region was examined and prepped and drapped in the usual sterile fashion. Using image intensifier in AP, oblique
and lateral projections landmarks of the intended neuroforamina was mapped out.
Next, a 25 gauge Quincke needle was advanced and negotiated to the posterior margin of the neuroforamen and verified on
multiplanar imaging. Aspiration was negative for blood, air, and cerebral spinal fluid. No paresthesias were provoked with
needle placement.
Injection of of contrast material demonstrated foraminal filling, perineural highlight of the nerve root. There was no evidence for
subdural, subarachnoid, or intravascular uptake.
Next, a solution containing lidocaine and Decadron was incrementally injected. The needle was flushed and removed.
The procedure was repeated for the other listed level(s) (If LISTED). Decadron 10mg was dived between all injections.
Fluoroscopic images were saved and transferred to PACS. The patient was transferred to the PACU and tolerated the
procedure well with no complications.
Would this be considered one level or two?
From everything I can find it should be listed example c5/6 for one level and say c6/7 for the next level no matter how many injections.
The way I read this it would only be cpt 64479-LT. Is this correct? Can someone help me with some guidance on this?