Wiki Pain Mgmt Coding


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Need a little help with this procedure CPT and dx help would be appreciated. Not sure if I agree with what I have coded in the past now that I look at it a bit further and wanted to know what others are coding. :rolleyes:

Procedure: Intrathecal catheter study.

Preoperative diagnosis: Generalized pain.
Post operative diagnosis: As above, normal catheter study.

Indications/History: 47 year old patient with intrathecal pump and catheter with recent increase in generalized pain. Question of intrathecal catheter patency issue.

Procedure Description: After informed consent obtained from patient, she was brought to OR, positioned on fluoroscopy table. Skin over intrathecal pump was prepped and draped in a sterile manner using Duraprep. Under fluoroscopy, a 22 gage non-coring needle was fluoroscopically directed into the side access port of the Medtronic Synchromed II pump. 2 ml of clear fluid was easily aspirated from the side port. Next, 2 ml of fresh Isovue 300 contrast material was injected through the catheter. Under fluoroscopy, contrast material was observed to freely flow out of the distal tip of the intrathecal catheter. The fluoroscopic image demonstrating contrast flow from catheter tip was saved to the patient's permanent medical reocrd. The needle was removed from the pump side access port. The patient tolerated the procedure well. No complications occurred. Patient taken to recovery area and pump was programmed to deliver priming bolus. Patient discharged from Surgery Department having met criteria. Patient to follow up in Dr's office within one week.