chembree
Guru
INDICATION: Severe left thoracic paraspinal musculature and intercostal pain.
PROCEDURE: The patient was informed and consented for the procedure then placed in the prone position on the CT scan table. The patient was prepped and draped in a sterile technique. 1% lidocaine without epinephrine was utilized as a local anesthetic.
Under CT guidance, a 25-gauge needle was advanced from a posterior approach and into the left T9 paraspinal musculature. Needle tip position within the musculature was confirmed with CT imaging. CT images were sent to PACS for documentation. Under CT guidance, a second 25-gauge needle was advanced from a posterior approach into the left T9-T10 neural foramen. Needle tip position within the neural foramen was confirmed with CT imaging. CT images were sent to PACS for documentation. 1 mL of 1% lidocaine without epinephrine, 1 mL of 0.5% bupivacaine and 40 mg of Depo-Medrol was injected into each needle. The needles were then removed. The patient described 8 out of 10 pain prior to the procedure and 0 out of 10 pain post procedure.
IMPRESSION: CT guided left T9 paraspinal musculature steroid injection and left T9-T10 neural foraminal steroid injection.
Can someone help me with the code for the paraspinal musculature injection? and can this procedure be coded with the 64479?
PROCEDURE: The patient was informed and consented for the procedure then placed in the prone position on the CT scan table. The patient was prepped and draped in a sterile technique. 1% lidocaine without epinephrine was utilized as a local anesthetic.
Under CT guidance, a 25-gauge needle was advanced from a posterior approach and into the left T9 paraspinal musculature. Needle tip position within the musculature was confirmed with CT imaging. CT images were sent to PACS for documentation. Under CT guidance, a second 25-gauge needle was advanced from a posterior approach into the left T9-T10 neural foramen. Needle tip position within the neural foramen was confirmed with CT imaging. CT images were sent to PACS for documentation. 1 mL of 1% lidocaine without epinephrine, 1 mL of 0.5% bupivacaine and 40 mg of Depo-Medrol was injected into each needle. The needles were then removed. The patient described 8 out of 10 pain prior to the procedure and 0 out of 10 pain post procedure.
IMPRESSION: CT guided left T9 paraspinal musculature steroid injection and left T9-T10 neural foraminal steroid injection.
Can someone help me with the code for the paraspinal musculature injection? and can this procedure be coded with the 64479?