The report below describes spinal injection procedures in detail, noting how many of these procedures are bundled into one code. Continue reading below to learn more!
Do you have a complicated surgery case that needs help with coding? RT Welter would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient-protected health information and organization identifiers. RT Welter will not use any medical records submitted in which PHI is not removed and protected.
Spinal Injection Procedures
By: Sheila Haynes – Coding and Compliance Manager
There have been many changes over recent years in pain management CPT codes, many spinal injection procedures have been bundled and include the guidance, while others like some arthrocentesis, arthrograms, and myelograms still need the guidance coded separately. However, year over year more and more of these procedures are getting bundled into one code.
Surgical Op Report Example: Left C6 Selective Nerve Root Injection
Reason for Study: Cervical Radiculopathy
Clinical History: Cervical Radiculopathy
Technique: Medication reconciliation form reviewed an any changes related to this procedure resolved. Standard technical protocol was utilized.
Dosimetry: CTDI:7mGy; DLP: 246mGy-cm (Note: These does indicators do not reflect the effective patient dose, but are metrics based on standardized CT phantoms. The effective dose may vary widely depending on body size, shape, and other patient factors).
Dose reduction was performed with automated exposure control, iterative reconstruction technique and/or adjustment of the mA and /or kV for patient size.
Procedure: Under sterile conditions, a 25-guage needle was placed into the left C5-6 foramen and a left C6 selective nerve root injection was performed using 10mg of dexamethasone and 2 mL of 1% Xylocaine. Patient tolerated the procedure well. The CT images show appropriate needle position within the left C5-6 foramen.
Findings: The needle is seen appropriately positioned in the left C5-6 foramen posterior aspect
Performed procedures: Left C6 selective nerve root injection
Impression: Successful left C6 selective nerve root injection as discussed above
• CPT: 64479 Injection anesthetic agent and/or steroid; transforaminal epidural, with imaging guidance cervical or thoracic, single level
• ICD-10: M54.12 Cervical Radiculopathy
RT Welter & Associates pg. 1 Eff. 1/14/2022