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Orthopedic Coding Alert

READER QUESTIONS:

Make Multiple-Injection Pay Easier

Question: Our surgeon performed a lumbar epidural steroid injection (LESI) and an SI joint injection during the same session. He used fluoroscopy to help with needle placement. How should I report this encounter? 


Florida Subscriber


Answer: Begin by reporting the LESI with 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).
 
Many surgeons use fluoroscopy or CT to verify needle placement within the SI joint.

Therefore, you should report the fluoroscopy with 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

Finally, report 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) for the SI joint injection.


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