Lumbar Epidural Coding

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Please help code:

Diagnosis:
1. Lumbar disc protrusion
2. Lumbar radiculopathy
3. Lumbar facet hypertrophy

Procedure:
1. Lumbar epidural steroid injection at L4-L5
2. Bilateral facet joint injection at L4-L5 and L5-S1
3. Interpretation of arthrograms of facet joins L4-L5 and L5-S1
4. Epidurogram
5. Injection of Marcaine and Depo-Medrol
6. Fluoroscopy

At L4-L5, 10 cc of 1% Lidocaine was used to infiltrate the area with #25-gauge needle. Next, a #17-gauge, 3.5-inch Tuohy needle was inserted and advanced until good loss of resistance to normal saline was obtained at this level. After negative aspiration for blood or CSF, 3 cc of Isovue-200 was injected, which showed diffuse epidurogram at L4-L5, which was then confirmed on the lateral position. Then, a solution containing 4 cc of 0.25% Marcaine and 40 mg of Depo-Medrol was injected, which showed the same distribution as the dye.



The L4-L5 and L5-S1 facet joints were identified by fluoroscopy unit in the oblique position. A 25G Quincke tip needle was then advanced to each joint under fluoroscopy. The similar routine was then repeated for the other side. Next, the positions of all needles were confirmed, and each one was injected with a solution containing 0.5 cc Isovue solution, which revealed arthrogram of each joint. Then, each facet joint was injected with 0.5 cc of 0.25% Marcaine and 10 mg of Depo-Medrol.



All the needles were then removed. The areas were cleaned and covered with Band-Aid.



The patient tolerated the procedure well and was taken to the recovery room and discharged home in a good condition with a follow-up visit with me at my office.
 

dwaldman

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64493-50 721.3
64494-50
62311 722.10 (724.4 due to disc displacement; if so it would not be separately reported)


The epidurogram and arthrogram represent typical documentation for anatomy and needle localization and do not support a formal diagnostic study . For 77003 at the same level as a procedure that includes fluorscopy (77003) makes me lean towards not reporting 77003-26 59 for that scenario.
 

brockorama01

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FYI: Please inquire with the pain physician why he would want to do medical branch blocks and an epidural at the same time.

Mr. Waldman's coding advice is correct, but it will be a hassle to get paid. Many carriers would deny the claim for medical necessity or bundling. The MBB is to number the medial branch nerves to see if they are the cause of the patient axial back pain. ESI's have a local and steroid to reduce inflamation of nerves for radicular pain. Wouldn't the local and steroid from the ESI bleed over to the MBB? How do you know which worked...the ESI or MBB? Are you treating the radicular or axial pain?

Also, note that the physician may have a very good answer, but remind them that their answer VERY simple and clear. Their target audience are paper shufflers with little experience in pain mgt.

Just a thought...from another paper shuffler.


Brock Berta
 
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