transforaminal epidural steroid injection HELP

chrissywa

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I need help with transforaminal epidural injections for ASC coding, one of my physician dictates 2 different ways I copied them below and I'm a little confused, i was told look for needle count and to the foramen. :(

Would the below procedure be 64479LT,64480LT?
Left-sided C6-7 transforaminal epidural steroid injection.

INDICATIONS: In order to better diagnose and treat the patient's spinal pain related symptoms, it was medically necessary to perform fluoroscopically-guided contrast-enhanced transforaminal epidural injection of the left C6 and C7 nerve roots.

DESCRIPTION OF PROCEDURE: After visualizing the foramen and pertinent anatomic structures with fluoroscopy, local anesthetic using 1% lidocaine with epinephrine was administered to the site. New bottles of medication were used to perform an injectate of 1 mL of dexamethasone 4 mg/mL and 1 mL of normal saline. Using fluoroscopic guidance, a 25-gauge tip 3-1/2-inch spinal needle was advanced to the superior articular pillars of left C6 and C7 nerve root foramen to access the epidural space. [/COLOR] [/U][/U]An oblique and AP projection was obtained to confirm position. After dry aspirate was obtained, 2 mL of Omnipaque 240 was injected using live fluoroscopy and digital subtraction ensured there was no vascular, subdural, or subarachnoid flow. Once needle placement was appropriately confirmed, a total volume of 2 mL including 1 mL of dexamethasone 4 mg/mL and 1 mL of normal saline was injected, 1 mL at each level.


And

Would the below be 64483RT 64484RT?
PROCEDURE PERFORMED: Right-sided L5-S1 transforaminal epidural steroid injection.

DESCRIPTION OF PROCEDURE: The foramen noted above was visualized. The soft tissue and overlying structures were infiltrated with 1% lidocaine with epinephrine. A 25-gauge tip 5-inch needle was injected towards the pars interarticularis and foramen. Under AP visualization, the needle was advanced. It did not go beyond 6 o'clock position of the pedicle. A 25-gauge tip 5-inch needle was positioned over the S1 foramen. The needle was advanced and walked off the sacrum into the foramen. Dry aspirate was obtained. Lateral projection was used to confirm position. Then, 2 mL volume of Omnipaque 240 was injected with flow of contrast without vascular uptake. Radiographs were obtained for documentation purposes. Then, 4 mL volume containing 1 mL of dexamethasone 4 mg/mL and 3 mL of 0.25% bupivacaine was injected, 2 mL at each level.


Thank you for any advice that can be offered;)
 
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Hi

As for I concerned for the Left-sided C6-7 transforaminal epidural steroid injection we can code 64479-LT and 64480-LT as the description says the needle was advanced to the superior articular pillars of left C6 and C7 nerve root foramen to access the epidural space, So two levels we have to pick and for the 2nd one needle was advanced into S1 level so 64483-RT will be ok.

Hope it will be helpful.
 
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