tschrader
Networker
I am wanting to some clarification on this code. As it states in the CPT book multiple adhesiolysis sessions for one day. So if the provider is injecting for one session, do you still use this code or another code. I have dictation samples where its only one injection done not multiple sessions. Of course the doctor states that this is the code to use. Here is an example of the dictation that he dictates:
Pre/Post Procedure Diagnosis:
1. Lumbar Intervertebral Disc Disease
2. Lumbar Spinal Stenosis
3. Lumbar Radiculopathy
4. Chronic Low Back Pain
5. Failed Back Surgery Syndrome / Postlaminectomy Syndrome
Procedure:
1. Caudal Catheter Epidural Steroid Injection with Lysis of Adhesions
2. Fluoroscopic Needle Localization
Procedure Summary:
The risks and benefits of the procedure were discussed with the patient who agreed to proceed via written consent. The patient was escorted to the fluoroscopy suite and placed in the prone position on the procedure room table. The sacral region was cleaned with chlorhexidine x 3 then draped in the usual sterile fashion. A time out was performed to confirm this was the correct patient, procedure, and location. All pressure points were checked, padded, and verbal communication was maintained with the patient throughout the procedure.
Lateral fluoroscopy was used to identify the sacral hiatus. The skin and subcutaneous tissue overlying the area was anesthetized with 1% Lidocaine. A 16-gauge RX epidural needle was then advanced percutaneously through the anesthestized skin tract under fluoroscopic guidance into the caudal epidural space. Next, a RX brevi catheter was advanced under intermittent fluoroscopy to the L5 vertebral level. After negative aspiration for blood or CSF, a volume of 2 mL of Omnipaque 180 was injected under live fluoroscopy. This revealed good epidural spread, with no evidence of loculation, vascular run-off, or intrathecal spread. Subsequently, a volume of 5 mL of hyaluronidase for adhesiolysis followed by _5 mL of 15 mg of dexamethasone_ mixed with 1 mL of bupivacaine and normal saline was injected without resistance. The catheter and needle were removed as a single unit and the catheter tip was noted to be intact. A bandage was applied over the needle entry site and the patient was escorted to recovery.
The patient tolerated the procedure well and and there were no complications. After being monitored post-procedure, the patient was discharged to home in stable condition without any new neurologic deficit.
Thank you!
Pre/Post Procedure Diagnosis:
1. Lumbar Intervertebral Disc Disease
2. Lumbar Spinal Stenosis
3. Lumbar Radiculopathy
4. Chronic Low Back Pain
5. Failed Back Surgery Syndrome / Postlaminectomy Syndrome
Procedure:
1. Caudal Catheter Epidural Steroid Injection with Lysis of Adhesions
2. Fluoroscopic Needle Localization
Procedure Summary:
The risks and benefits of the procedure were discussed with the patient who agreed to proceed via written consent. The patient was escorted to the fluoroscopy suite and placed in the prone position on the procedure room table. The sacral region was cleaned with chlorhexidine x 3 then draped in the usual sterile fashion. A time out was performed to confirm this was the correct patient, procedure, and location. All pressure points were checked, padded, and verbal communication was maintained with the patient throughout the procedure.
Lateral fluoroscopy was used to identify the sacral hiatus. The skin and subcutaneous tissue overlying the area was anesthetized with 1% Lidocaine. A 16-gauge RX epidural needle was then advanced percutaneously through the anesthestized skin tract under fluoroscopic guidance into the caudal epidural space. Next, a RX brevi catheter was advanced under intermittent fluoroscopy to the L5 vertebral level. After negative aspiration for blood or CSF, a volume of 2 mL of Omnipaque 180 was injected under live fluoroscopy. This revealed good epidural spread, with no evidence of loculation, vascular run-off, or intrathecal spread. Subsequently, a volume of 5 mL of hyaluronidase for adhesiolysis followed by _5 mL of 15 mg of dexamethasone_ mixed with 1 mL of bupivacaine and normal saline was injected without resistance. The catheter and needle were removed as a single unit and the catheter tip was noted to be intact. A bandage was applied over the needle entry site and the patient was escorted to recovery.
The patient tolerated the procedure well and and there were no complications. After being monitored post-procedure, the patient was discharged to home in stable condition without any new neurologic deficit.
Thank you!
