steroid injection s3 vertebral body

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Pls help me coding this procedure:
Thanks in advance!

Informed consent was obtained prior to the procedure during which the risks,
benefits, and alternatives to the procedure were discussed with the patient or
their surrogate and they wished to proceed. The site was cleaned and draped in
the usual sterile fashion using 2% chlorhexidine solution and a full body
sterile drape was applied. Maximal sterile technique was used including hand
hygiene, cap, mask, gown and sterile gloves. The site was anesthetized with 7
cc of 1% lidocaine subcutaneously. The procedure was performed using sterile
conditions, pulse oximetry and hemodynamic monitoring.

Fluoroscopy was used to localize the S3 were well in the midline and the skin
was anesthetized as described above. An 18 gauge needle was placed down on the
S3 over Y posteriorly and 8 mg of Depo-Medrol and 5 ml of 0.25% Marcaine were
instilled. The patient described her pain has 5/10 prior to the procedure and
the pain was completely relieved by the procedure with no pain immediately after
the procedure.

Contrast used:None

Fluoroscopy time:Less than 1 minute

IMPRESSION:

SUCCESSFUL FLUOROSCOPICALLY GUIDED STEROID AND MARCAINE INJECTION ON THE
POSTERIOR ASPECT OF THE S3 VERTEBRAL BODY WITH COMPLETE RELIEF OF THE PATIENT'S PAIN SYMPTOMATOLOGY
 
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Good Morning!

Based on your supplied note, please see:

64483
Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

I would suggest having a discussion with your physician to better define patient's positioning for the procedure, as well as the actual space where the injectible was "delivered" to the patient. This note is weak, at best.

Lastly, please note that the fluoro is included either way, and not billable separately. Bi-lateral reporting (modifier -50) is OK on 64483.

Good luck!
 
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