Attempted Myelogram???

Lynda Wetter

True Blue
Local Chapter Officer
Messages
511
Location
Richmond Virginia
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WHAT CPT'S AND/OR MODS WOULD BE APPROPRIATE FOR THIS.....?
Reason for Study: NERVE ROOT ANEURYSM

Reason For Visit: LEFT BRACHIAL PLEXUS PALSY,LEFT AXILLARY ART INJ

Procedure: Attempted cervical myelogram.

Contrast: Isovue-300M 5 ml.

Medications: 1% lidocaine local anesthesia.

Complications: Unable to access the thecal sac at L3-L4 or L4-L5
levels.

Procedural details: The risks, benefits alternatives of the procedure
including but not limited to the risks of bleeding, infection, damage
to the nerve roots, spinal cord, vessels, nerves or other nearby
structures, pain, weakness, CSF leak, headache, allergy to
medications or contrast materials and inability to perform the
procedure were explained the patient. All the patient's questions
were answered. Patient stated that he wished to proceed with the
procedure. Informed written consent was obtained.

The patient was placed in a prone position on the fluoroscopic table.
Skin of the lumbar spine was prepped and draped usual sterile
fashion.
1% lidocaine was used for local anesthesia. Using fluoroscopic
guidance in the anterior-posterior and lateral projections, a
22-gauge spinal needle was advanced to the level the thecal sac at
the L3-L4 level. Stylet was removed. However, no CSF was obtained.
The needle was repositioned several times. However, no CSF could be
obtained. Small contrast injection opacified the epidural space.
Needle was repositioned again and a small contrast injection
opacified the epidural space. At this point, needle was removed and
attempts were made to access the thecal sac at the L4-L5 level with
similar outcome. At this point, Dr. ABC made attempts to
access the thecal sac but again was unable to obtain CSF and small
contrast injection opacified epidural space. As such, the procedure
was terminated. Patient tolerated procedure well.

The case was discussed the patient and the patient's wife as well as
Dr. XYZ. Dr. XYZ decided that the cervical myelogram was still
necessary. Further attempts with either a high lumbar puncture or
cervical puncture could be performed.

Impression:

1. Unsuccessful attempt to access the lumbar thecal sac for planned
cervical myelogram.

Plan:

1. Patient for routine postprocedure observation.
 

jmcpolin

True Blue
Messages
841
Location
Salt Lake City
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I would bill the 62284-53, 77003-59 the procedure was aborted but there was still fluoro used to attempt the injection, but no diagnostic exam was done.
 
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