Anesthesic injection at hardware site - how to code??

alannae

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This is a new one for me. Looks like he's trying to verify the cause of the patient's pain. How would you code this?


PROCEDURE:
1) Right L5 pedicle screw injection
2) Left L5 pedicle screw injection
3) Right S1 sacral screw injection
4) Left S1 sacral screw injection
5) Fluoroscopic needle guidance

TECHNIQUE:
History and physical reviewed. Consent obtained. Pt was taken to the procedure room and assisted into the prone position on the OR table. Time-out was taken to identify the correct patient, procedure and side prior to starting the procedure. With the patient lying in a prone position, the patient was prepped and draped in the usual sterile fashion using ChloraPrep and a fenestrated drape. The right L5 pedicle was screw determined under fluoroscopy with a slight ipsilateral oblique view. Local anesthetic was given by raising a wheal and going down to the hub of a 27-gauge 1.25-inch needle. Then a 22-gauge 3.5-inch Quincke needle was introduced through the skin and advanced to the tip of the right L5 pedicle screw. The final position was checked by oblique fluoroscopy of the C-arm to the right and left as well as tilting to the head and foot to confirm appropriate needle tip placement at the head of the screw. After a negative aspiration, 2 mL of the above medication was then injected slowly. Patient could feel the medication being injected. He reports that this location is NOT the site of his usual pain. The needle was removed.
The right S1 screw was determined under fluoroscopy with a slight ipsilateral oblique view. Local anesthetic was given by raising a wheal and going down to the hub of a 27-gauge 1.25-inch needle. Then a 22-gauge 3.5-inch Quincke needle was introduced through the skin and advanced to the tip of the right S1 screw. The final position was checked by oblique fluoroscopy of the C-arm to the right and left as well as tilting to the head and foot to confirm appropriate needle tip placement at the head of the screw. After a negative aspiration, 2 mL of the above medication was then injected slowly. Patient could feel the medication being injected. He reports that this location is NOT the site of his usual pain. The needle was removed.
The left L5 pedicle was screw determined under fluoroscopy with a slight ipsilateral oblique view. Local anesthetic was given by raising a wheal and going down to the hub of a 27-gauge 1.25-inch needle. Then a 22-gauge 3.5-inch Quincke needle was introduced through the skin and advanced to the tip of the left L5 pedicle screw. The final position was checked by oblique fluoroscopy of the C-arm to the right and left as well as tilting to the head and foot to confirm appropriate needle tip placement at the head of the screw. After a negative aspiration, 2 mL of the above medication was then injected slowly. Patient could feel the medication being injected. He reports that this location is NOT the site of his usual pain. The needle was removed.
The right S1 screw was determined under fluoroscopy with a slight ipsilateral oblique view. Local anesthetic was given by raising a wheal and going down to the hub of a 27-gauge 1.25-inch needle. Then a 22-gauge 3.5-inch Quincke needle was introduced through the skin and advanced to the tip of the right S1 screw. The final position was checked by oblique fluoroscopy of the C-arm to the right and left as well as tilting to the head and foot to confirm appropriate needle tip placement at the head of the screw. After a negative aspiration, 2 mL of the above medication was then injected slowly. Patient could feel the medication being injected. He reports that this location DEFINITELY IS the site of his usual pain. The needle was removed.
The procedure was completed without complications and was tolerated well. The patient was monitored after the procedure. The needle was removed.
The patient (or responsible party) was given post-procedure and discharge instructions to follow at home. The patient was discharged in stable condition. A follow up appointment was made.

Pre-procedure pain score: 9/10 with pain reproduced by extension and rotational motion of the lumbar spine

Post-procedure pain score: 0/10 with pain not reproduced by extension and rotational motion of the lumbar spine

Patient reports 100% relief of his usual pain which appears to be caused by the left S1 screw.



TIA for sharing your knowledge and experience :D
 
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