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paricapsular injection C4-5 CPT

Mike Posted Fri 18th of April, 2014 15:52:20 PM

The physician could not access the C4-5 joint for an intraarticular facet injection. He instead performed a paricapsular injection but only injected lidocain/Decadron solution around the posterior and lateral borders of the joint.

What would the code be 64490-52 or 20550-20552??

SuperCoder Answered Mon 21st of April, 2014 08:47:45 AM

Anatomy: The deep muscles (sometimes referred to collectively as paraspinal muscles) form a thick mass on each side of the spine, extending from the base of the skull to the sacrum. This muscle mass consists of many separate, overlapping muscles of different lengths, attached to the spinous or transverse processes of different vertebrae. The semispinalis capitis, the splenius capitis and the multifidus muscles are some of the deep paraspinal muscles of the neck region.

Injections of trigger points into one or two muscles would be billed with 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) whereas trigger point injections into three or more muscles would be reported with 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscle(s)). Compliant documentation for trigger point injections would include the specific muscles injected rather than use of a broad term such as paraspinal or pericapsular

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