Epidurogram documentation

kkmink

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Can anyone provide a shining example of documentation for an epidurogram (CPT 72275)?
 

amitjoshi4

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Informed consent obtained and risks and benefits were explained. The patient was placed prone on fluoroscopy table. The skin from L2 to S2 was prepped with povidone‑iodine and draped in sterile manner. Aseptic technique was used at every stage of the procedure. Heart rate, blood pressure, respiratory rate, and oxygen saturation were monitored throughout the procedure.

Fluoroscopy was used and left S1 foramen was identified. The skin overlying the area was infiltrated and anesthetized with 2.5 mL of 1% preservative free lidocaine. A 22‑gauge 3½-inch spinal needle was inserted and initially guided under an AP view. Under AP visualization, the needle was advanced until it was felt to go firmly into the S1 foramen. The C‑arm was then slightly rotated toward the lateral view to confirm the needle position. A 1 mL of Omnipaque dye was injected to allow visualization of flow into the posterior epidural space and along the nerve root. There was no evidence of vascular flow. The aspiration was performed without evidence of blood or CSF.

A 3 mL mixture of 2 mL of triamcinolone (40 mg/mL) with 1 mL 1% preservative-free lidocaine were injected at the S1 level. A total of one spinal needle was used for this procedure. Intravenous conscious sedation was not used

AP fluoroscopic view is reviewed.This demonstrates a spinal needle at the L5-S1 intralaminar space. There appears to be flow into the epidural space. No evidence of vascular flow or flow into adjacent compartments.

The patient was transported to recovery. Vital signs were stable and the injection sites were cleaned. The patient was discharged to home in care of his wife. He was told to come with any concerns or questions otherwise see me in two weeks for follow up.
 

mbort

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I see minimal documentation in the above note for the 72275,

"A 1 mL of Omnipaque dye was injected to allow visualization of flow into the posterior epidural space and along the nerve root. There was no evidence of vascular flow. The aspiration was performed without evidence of blood or CSF"

I personally feel that there is more documentation to support the Fluoroscopy code 77003. Since these codes bundle with one another, I would use the 77003 instead of the 72275. Anyone else see this my way?
 

kkmink

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I agree with mbort. That is my conundrum. My research says that "a typical report describes the flow of contrast into the epidural space (which the example does), any blockages found, and the flow along the nerve roots."
 

amitjoshi4

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Hi,

Lets be Precise in this. If we see the section notes under 72275, it clearly states that "To report the injection procedure consult CPT codes 62280-62282, 62310-62319, 64479-64484, and 0027T. Code 72275 includes code 77003. Report 72275 only when an epidurogram is performed, images documented, and a formal radiology report is written."

It means that a formal epidurography report must be there separately. And also per CDR of 72275 "A radiologic imaging examination is performed on the veins lining the spinal canal. Contrast is injected into the epidural space under direct fluoroscopy. Examining the flow of contrast in the epidural space around the nerves to be studied aids in the diagnosis of intervertebral disc herniations, narrowing and swelling around the nerve and/or nerve roots, and compressive lesions."

So the report will look like this.

1. The actual injection Procedure(Informed consent obtained and risks and benefits were explained. The patient was placed prone on fluoroscopy table. The skin from L2 to S2 was prepped with povidone‑iodine and draped in sterile manner. Aseptic technique was used at every stage of the procedure. Heart rate, blood pressure, respiratory rate, and oxygen saturation were monitored throughout the procedure.

Fluoroscopy was used and left S1 foramen was identified. The skin overlying the area was infiltrated and anesthetized with 2.5 mL of 1% preservative free lidocaine. A 22‑gauge 3½-inch spinal needle was inserted and initially guided under an AP view. Under AP visualization, the needle was advanced until it was felt to go firmly into the S1 foramen. The C‑arm was then slightly rotated toward the lateral view to confirm the needle position. A 1 mL of Omnipaque dye was injected to allow visualization of flow into the posterior epidural space and along the nerve root. There was no evidence of vascular flow. The aspiration was performed without evidence of blood or CSF.

A 3 mL mixture of 2 mL of triamcinolone (40 mg/mL) with 1 mL 1% preservative-free lidocaine were injected at the S1 level. A total of one spinal needle was used for this procedure. Intravenous conscious sedation was not used

The patient was transported to recovery. Vital signs were stable and the injection sites were cleaned. The patient was discharged to home in care of his wife. He was told to come with any concerns or questions otherwise see me in two weeks for follow up.)

2. Epidurography Report(AP fluoroscopic view is reviewed.This demonstrates a spinal needle at the L5-S1 intralaminar space. There appears to be flow into the epidural space. No evidence of vascular flow or flow into adjacent compartments)

I think the picture will be more clear in this bifurcation.

Thank You
 
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