Anesthesia Coding Alert

Question: A physician dictated that a patient had a paravertebral sacroiliac (SI) joint and single nerve root injection, without fluoroscopy. I assume 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]) is correct for the paravertebral SI joint injection, but I am not sure what to use for the nerve root injection. The client used 64483 (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), but I thought this code required fluoroscopy.

New Jersey Subscriber
 
Answer: Although the physicians notes say the procedure was performed without fluoroscopy, many practitioners and coders do not see how an SI joint injection or selective nerve root block can be performed effectively without fluoroscopic guidance. For an ideal situation bill 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) for a unilateral SI joint injection. Because the SI injection is into a joint instead of the epidural space, some coders prefer 20610* (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) instead of 62311, which indicates epidural space.
 
You do not indicate which nerve root was injected. If your documentation reflects a lumbar facet joint injection for a nerve block (these are often performed with SI joint injections), 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) would apply. If not, the nerve blocks and injections are covered by 64445*-64450* (codes related to various injection sites for anesthetic agent). Some carriers may also accept 64483, which your client used for a unilateral, single-level selective nerve root block in the lumbar/sacral region.