Aborted ESI


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Physician wants to bill for an aborted Interlaminar ESI that was converted to a Transforaminal ESI due to difficult anatomy. I have posted the note below.

Can he bill for both the aborted ILESI and the the TFESI?

Thanks for your help!


Using fluoroscopy, the thoracic vertebral bodies were identified counting from T12. A marker was placed over the intervertebral disc space just to the right of midline, at the level specified above. The superficial tissue was then anesthetized with 1 cc of 1% preservative free lidocaine using a 27-gauge 1.5-inch needle. A 20-gauge 3.5-inch Tuohy needle was then passed through the previously anesthetized tissue. The needle was advanced under fluoroscopic guidance down to the lamina using AP visualization. Using lateral visualization and the loss-of-resistance technique, the needle was then attempted to be advanced through the ligamentum flavum into the epidural space was easily located. However, owing to the difficult adjacent anatomy from degenerative bony changes, the entry into the epidural space proved difficult despite multiple attempts. At this point, the decision was made to attempt interlaminar approach through the interspace one level below. The needle was then removed.

Using fluoroscopy, the lumbar vertebral bodies were counted from T12 and identified. A right oblique view was used to maximally visualize the foramen. The superficial tissue overlying this was marked and anesthetized with 1-2 cc of 1% preservative-free lidocaine. A 22-gauge 3.5-inch spinal needle was then passed through the previously anesthetized tissue and advanced under fluoroscopic guidance towards the superior aspect of the foramen. AP and lateral views were then used to guide the needle within the foramen until it was under the pedicle at approximately 6 o'clock. After checking for negative withdrawal of blood or CSF through the needle, proper placement was verified using approximately 0.5 mL of contrast injected under live fluoroscopy, producing an epidurogram/epineurogram. No vascular flow was seen. A spot film was taken. This was done in both AP and lateral views, individually. The contrast evaluation was also then performed using digital subtraction techniques, both in AP and lateral planes.
No vacular flow was seen. A test dose of 0.5 cc of 1% preservative-free lidocaine was administered. The patient remained asymptomatic, and vital signs were stable after one minute. Then a solution containing 6 cc of Decadron (4 mg/cc) was slowly administered without difficulty. The needle was then flushed with an additional 0.25 cc of 1% preservative-free lidocaine and then removed.


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Below is from a Medtronics 2009 webinar presented by Joanne Mehmert: Pain Management Billing and Coding

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Q I have a provider who did a right sided L4-L5 transforaminal epidural steroid injection and interlaminar epidural injection at L4,L5,S1 How would I code for this

A When two different surgical approaches are used to accomplish the same goal, it is not appropriate to report both procedures. In the situation described, the injections are made at the same spinal level, a contiguous anatomical region; it would not be appropriate to report both procedures. A transforaminal epidural 64479/64483 is mutually exclusive to a translaminar epidural 62310/623111.

The CCI shows that a transforaminal epidural 64479/64483 is mutally exclusive to a translaminar epidural 62310/62311. Although a bypass modifier (59) is allowed, the modifier is not appropriate when the injection is at the same spinal level to treat the same condition.

If the provider attempts to perform the injection using the interlaminar technique and finds that the dye does not spread, then changes his/ approach to the transforaminal, only the transforaminal injection should be reported. AMA literature show examples of this coding principle for endoscopic procedures converted to open procedures---report only the "open" code.