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Nelli Posted Fri 01st of December, 2017 13:11:02 PM
Patient had a Lumbar/Sacral Transforaminal Epidural Steroid Injection Targeting Left L5 and S1 Nerve roots. There is some confusion regarding if L5 and S1 is one level or 2 levels. I think the correct code is 64483. Can you please clarify and e give me some reference for future use. Op note PROCEDURE: Lumbar/Sacral Transforaminal Epidural Steroid Injection Targeting Left L5 and S1 Nerve roots The skin over the intended target site, the “6 o’clock” position of the L5 pedicle, was marked prepped with chlorhexidine swab, and draped in the usual sterile fashion. With sterile technique, the skin and subcutaneous tissues were anesthetized using 1% lidocaine without epinephrine. The tip of the 22 gauge, 5.0 inch needle was advanced toward the “6 o’clock” position of the L5 pedicle under intermittent fluoroscopic guidance. Confirmation of proper needle position was made with AP, oblique, and lateral fluoroscopic views. After negative aspiration for blood and cerebrospinal fluid, Omnipaque 240 dye was injected using live fluoroscopy. Fluoroscopic imaging revealed clear outline of the L5 spinal nerve with proximal spread of agent through the neural foramen into the anterior epidural space without any evidence of vascular uptake. Then, a test dose of Lidocaine 1% was injected. After a full 90 seconds, there was no evidence of seizure, metallic taste, peri-oral numbness, or other indication of potential vascular uptake. Subsequently, injectate (10mg dexamethasone (10mg/mL) preservative free and 0.25% bupivacaine) was slowly administered. The spinal needle was re-styletted and removed. The patient tolerated the procedure well, and there was no evidence of procedural complications. This process was again repeated targeting the left S1 foramenAn AP approach was utilized with 15 degrees of cephalad tilt to align the sacral base. 5 degrees of ipsilateral left obliquity was added aligning the dorsal and ventral aspect of the left S1 foramen. With sterile technique, the skin and subcutaneous tissues were anesthetized using 1% lidocaine without epinephrine. The tip of the 22 gauge, 3.5 inch needle was advanced into the superolateral portion of the S1 foramen. Confirmation of proper needle position was made with AP and lateral fluoroscopic views. After negative aspiration for blood and cerebrospinal fluid, Omnipaque 240 dye was injected using live fluoroscopy. Fluoroscopic imaging revealed clear outline of the S1 spinal nerve with proximal spread of agent through the neural foramen into the posterior epidural space without any evidence of vascular uptake. Then, a test dose of Lidocaine 1% was injected. After a full 90 seconds, there was no evidence of seizure, metallic taste, peri-oral numbness, or other indication of potential vascular uptake. Subsequently, injectate (10mg dexamethasone (10mg/mL) preservative free and 0.25% bupivacaine) was slowly administered. The spinal needle was re-styletted and removed. The patient tolerated the procedure well, and there was no evidence of procedural complications.  
SuperCoder Answered Mon 04th of December, 2017 02:46:48 AM

Hi,

 

AAE does not provide coding for operative reports and chart notes. SuperCoder offers SuperCoding on Demand (SOD)

(http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can

contact (866)228-9252 or e-mail customerservice@supercoder.com for more information. Thanks !!

Nelli Posted Mon 04th of December, 2017 08:12:10 AM
what is the correct CPT code for Lumbar/Sacral Transforaminal Epidural Steroid Injection Targeting Left L5 and S1 Nerve roots
SuperCoder Answered Tue 05th of December, 2017 01:36:58 AM

Hi,

The appropriate CPT code would be 64483 - LT x 1 and 64484 - LT x 1.

Thanks

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