Wiki 64517 - superior hypogastric plexus block

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Breezy

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This is the note I have from the doctor. I coded this without any modifer 50 or RT or LT. I did that because I was thinking this code couldn't be bilateral per physician fee schedule. Is that correct or not correct? The MD wants to know why I don't use RT and LT?
Thanks if anyone can help out.
Karla



An informed consent was obtained. IV access was established. Patient was placed in the prone position on the fluoroscopy table. Monitors were applied. The low back was prepped and draped in the usual sterile fashion. Then 2% lidocaine was infiltrated intradermally and deeper midway between the lower costal margin and the iliac crest and just lateral to the bulk of the right paraspinal musculature. A 22G 7' needle was inserted through the skin wheal and advanced slowly under fluoroscopic guidance in an anterior, medial, and slightly superior direction until the tip of the needle lay approximately 1cm anterior to the right anterolateral aspect of the vertebral column at the inferior L5 level. This was confirmed in AP and lateral views. A small amount of Omnipaque 300 was injected, and appropriate spread of contrast was observed anterior to L5 in appropriate pattern. After negative aspiration, 8ml of 0.5% Marcaine solution was injected in 2- to 3-cc increments with negative aspiration before and after each small bolus injection. The needle was withdrawn. This was repeated in the same fashion on the left. Band-Aids were applied. There were no complications.
 
In CPT Changes 2004 when this code was introduced, the clinical example given included injections on each side with no indication that the code would be used twice.
I think that since you are blocking a plexus and not individual nerves that's why you can't code bilaterally.
 
Description of Procedure (64517)

I was looking at the example from CPT Changes 2004 for 64517 and did not see them describing a bilateral procedure with two separate needle placements.

The patient is taken to the operating room or procedure suite. He is placed in the prone position. EKG, blood pressure and pulse oximetry are applied. His back is prepared with Betadine. A spinal needle is inserted to the anterolateral spine at the L5-S1 interspace. Proper needle location is determined, employing radiological imaging guidance (reported separately). Radiographic contrast is then injected demonstrating flow in the pre-vertebral space, anterior to the psoas muscle fascia. After careful negative aspiration for blood, urine and CSF, local anesthetic is injected on each side. The patient is then transferred to the recovery room where he is carefully observed and monitored for early signs of complications. The complications of the procedure include puncture of the iliac vessels and bleeding, intravascular injection of local anesthetics with possible seizures or cardiovascular collapse, nerve injury to the cauda equina, or exiting spinal nerves, puncture of the ureters and other pelvic viscera. Infection is always a possibility, especially in immuno-suppressed cancer patients.
 
"Code 64517 was added to describe injection of an anesthetic agent into the superior hypogastric plexus. A superior hypogastric plexus block focuses on providing relief from pain in the pelvic area and requires a technique that is substantially different from other blocks. The physician must pass a needle through the L5-S1 interspace to inject the anesthetic. Code 64517 does not include fluoroscopic guidance. Therefore, fluoroscopy may be reported separately when performed."


"A spinal needle is inserted to the anterolateral spine at the L5-S1 interspace. Proper needle location is determined, employing radiological imaging guidance (reported separately). "

"After careful negative aspiration for blood, urine and CSF, local anesthetic is injected on each side."

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Sorry I do see where it says that it is injected on each side, I had focused on the previous information they were providing where it sounded like they were describing a single injection. It would be interesting to see a Q and A from the CPT Network on this code 64517 and 64530 when performed bilateral
 
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