NESmith
Expert
Description of the Procedure
With the patient having had an IV started and all routine monitoring intact, patient was placed in the prone position. A sterile meticulous prep of the entire lumbosacral area was performed and sterile draping was placed. Under fluoroscopic visualization, the Sacral hiatus was delineated and a 25-gauge needle was used to infiltrate the skin with 1% local lidocaine. A 18-gauge RACZ needle was then used and placed on the sacral canal using direct fluoroscopic visualization to access the peidural space. There were no patient complaints of paresthesia and hthere was no evidence of blood or CSF. At this point, an injection of Ominpaque 300 2 cc non-ionic contrast dye was perfomred and contrast was seen to extend through the epidural space.
For the purpose of diagnosis and interpretation, hard film copies were taken for the patient's record.
A RACZ cathether is then advanced in the epidural space. Adhesions were encountered by the catheter at the surgical site L5 S1 fusion area. Injection of 1 cc of Isovue 300 shows poor spread of the dye in the epidural space. These adhesions were broken down by hydrodisscetion with NSS and the mechanical action of the catheter. This was repeated until the spread of the radioopaque was noted to be homogeneous and adequate.
At this point, we prepared a solution containing 4 cc of preservative-free normal saline and 1 cc Kenalog(traimcinolene) 40 mg per ml was injected after aspirating for blood or CSF. The needle was subsequently withdrawn. All injection sities were covered with sterile dressings.
Does this represent CPT code 62264 or 62311?
Thank you as always for your help.
Reading to many different reports and trying to decide what is correct.
With the patient having had an IV started and all routine monitoring intact, patient was placed in the prone position. A sterile meticulous prep of the entire lumbosacral area was performed and sterile draping was placed. Under fluoroscopic visualization, the Sacral hiatus was delineated and a 25-gauge needle was used to infiltrate the skin with 1% local lidocaine. A 18-gauge RACZ needle was then used and placed on the sacral canal using direct fluoroscopic visualization to access the peidural space. There were no patient complaints of paresthesia and hthere was no evidence of blood or CSF. At this point, an injection of Ominpaque 300 2 cc non-ionic contrast dye was perfomred and contrast was seen to extend through the epidural space.
For the purpose of diagnosis and interpretation, hard film copies were taken for the patient's record.
A RACZ cathether is then advanced in the epidural space. Adhesions were encountered by the catheter at the surgical site L5 S1 fusion area. Injection of 1 cc of Isovue 300 shows poor spread of the dye in the epidural space. These adhesions were broken down by hydrodisscetion with NSS and the mechanical action of the catheter. This was repeated until the spread of the radioopaque was noted to be homogeneous and adequate.
At this point, we prepared a solution containing 4 cc of preservative-free normal saline and 1 cc Kenalog(traimcinolene) 40 mg per ml was injected after aspirating for blood or CSF. The needle was subsequently withdrawn. All injection sities were covered with sterile dressings.
Does this represent CPT code 62264 or 62311?
Thank you as always for your help.
Reading to many different reports and trying to decide what is correct.