One level or two opinions

Henson65

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So there has been some discussion in my office lately regarding one level or two when it comes to epidural injections. I know the description of 64483 is an injection into a single level lumbar or sacral. The follow is a sample of the documentation we get in the office, and we are seeing this exact op note code differently by different coders. We have had this coded as:
64483-LT
and
64483-LT
64484-LT

Procedure Performed: Left L4-L5 transforaminal epidural steroid injection under fluoroscopic guidance
Description: using 3.5 inch 20 gauge spinal needle, was advanced under fluoroscopic guidance into the anterior-superior aspect of the aforementioned transforaminal epidural space. Injection of 0.5cc ominpaque contrast showed good epidural spread and neurograms with no vascular or CSF uptake. 2cc of injectate containing 1cc of 1% lidocaine and 1cc of 40mg of triamcinolone was administered into each transforaminal epidural space without pain or paresthesia.

The difference of opinions comes from the documentation where it says anterior-superior and then talks about "each transforaminal space" some coders are saying it isn't clear that this is at two separate levels and others are saying it is clearly at two separate levels. Just trying to get a general consensus if other coders view this as one level or two. I have spoken to the provider in regard to if they are injecting two separate levels or just one......just looking to get opinions of others. Thanks in advance!!!!
 

thomas7331

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The documentation example you've given is a single injection at a single level. The code description is per 'level' of injection, it is not per vertebral segment. L4-L5 is the site of the injection is a single interspace, so this only counts as a single level, and would only get one code.
 

Henson65

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The documentation example you've given is a single injection at a single level. The code description is per 'level' of injection, it is not per vertebral segment. L4-L5 is the site of the injection is a single interspace, so this only counts as a single level, and would only get one code.
Thanks Thomas! If I get more opinions, I will post what the physician states he did in the procedure.
 

Henson65

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So this is what the physician is saying:
L4 and L5 are two different levels
L4-L5 is an injection for the L4 nerve root whereas the L5 nerve root is L5-S1. The injections are into each epidural space around each nerve root L4 and L5....anyone else have an opinion or thoughts?

I firmly believe it is only 1 level based upon the documentation, but some of our coders and the physician disagree....we are pretty much split 50/50 on this one.
 

thomas7331

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So this is what the physician is saying:
L4 and L5 are two different levels
L4-L5 is an injection for the L4 nerve root whereas the L5 nerve root is L5-S1. The injections are into each epidural space around each nerve root L4 and L5....anyone else have an opinion or thoughts?

I firmly believe it is only 1 level based upon the documentation, but some of our coders and the physician disagree....we are pretty much split 50/50 on this one.
If the physician is performing two injections here, my suggestion would be that he or she document each injection separately. Documentation of add-on procedures can become confusing when the providers try to summarize multiple injections into a single statement (and I've also seen payer auditors disallow codes when a provider does not separately document each procedure). The best practice is that each injection has its own note, or paragraph within the note, describing that entire procedure. So if the physician is treating both the L4 and L5 nerve roots, they should document the injection of the L4 nerve root (injected at L4-L5) and then document the injection of the L5 nerve root (injected at L5-S1). Then there would be no confusion. If they are just saying L4-L5, then it really is not clear if this is one or two injections - it certainly does not say so in the note above. Hope this helps some.
 

Henson65

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If the physician is performing two injections here, my suggestion would be that he or she document each injection separately. Documentation of add-on procedures can become confusing when the providers try to summarize multiple injections into a single statement (and I've also seen payer auditors disallow codes when a provider does not separately document each procedure). The best practice is that each injection has its own note, or paragraph within the note, describing that entire procedure. So if the physician is treating both the L4 and L5 nerve roots, they should document the injection of the L4 nerve root (injected at L4-L5) and then document the injection of the L5 nerve root (injected at L5-S1). Then there would be no confusion. If they are just saying L4-L5, then it really is not clear if this is one or two injections - it certainly does not say so in the note above. Hope this helps some.
Thanks Thomas! This does help a great deal and supports my initial findings and feelings on this documentation.....it's all about providing education in regard to documentation at times.
 
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to me in this senatorial the proper code to use is the primary code 64883. although the out come of the anesthesia result was 2 level targeting L4 -L5. However the in put was only one injection. Interns of the necessity of coding we view on the level time and inputs. Therefore, only one procedural code may be used for this treatment.
 
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