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Anesthesia Coding Alert

Reader Question:

Check Notes for Bilateral Documentation Before Coding

Published on Fri Dec 14, 2012

Question: One of our physicians submitted charges for 64483-50 with the following documentation: "Utilizing fluoroscopic guidance in the vertical plane, we were able to appreciate the pedicle, bilateral L4-L5. The skin was anesthetized superficially and deeply utilizing lidocaine 1% without epinephrine or preservatives in a 25-gauge 1-1/2-inch needle. An 23-gauge spinal needle was advanced to the 6 o’ clock position of the pedicle entering the superior aspect of the neural foramen. In the oblique plane of view, the needle was moved into a more anterior position inferior to the pedicle. The needle was in the most superior aspect of the neural foramen avoiding the vascular structures inferior to the nerve root. Cross-table lateral view indicated the needle in the most superior aspect of the neural foramen." I don’t understand how this confirms a bilateral procedure. Doesn’t the needle need to be inserted twice (once into the right intervertebral foramina and [...]
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