valramirez
New
Would this be coded as 64483, 64484 or just 64483? The documentation is confusing to me. I understood injecting the foramen was in the same 1 interspace (R L4-L5), but would this documentation support it at 2?
BRIEF PROCEDURE NOTE: The patient was brought into the fluoroscopy suite and was identified. The risks and
possible benefits of performing the procedure were again reviewed with the patient and a consent form had
already been signed and was confirmed to be on file. All additional questions were answered. The patient elected
to proceed.
The patient was placed prone on the fluoroscopy table and the right lower back area was prepped and
draped in the usual sterile manner. With the aid of fluoroscopy, the right L5 foramen was identified. The skin
overlying it was anesthetized with 1% preservative-free Lidocaine solution for comfort. A 22 gauge 5 inch spinal
needle was then carefully advanced under biplanar fluoroscopic guidance into the safe triangle of the right L5
foramen. Once the tip of the needle was felt to be inside the foramen, a final lateral view was obtained to confirm
placement. A small extension tube was attached to the needle and aspiration with a syringe was performed. No
CSF or blood was noted. Injection of 1 cc of Omnipaque (Iohexol 300) contrast dye revealed typical periradicular
flow and proximal epidural spread of contrast. There was no evidence of vascular flow. Then, 2.5 cc of a 5 cc
solution consisting of 2 cc Dexamethasone (4mg/ml) with a remainder of 1% preservative-free Lidocaine were
injected without difficulty. The needle and the extension tube were withdrawn from the patient. The same
procedure was repeated for the right L4 foramen.
BRIEF PROCEDURE NOTE: The patient was brought into the fluoroscopy suite and was identified. The risks and
possible benefits of performing the procedure were again reviewed with the patient and a consent form had
already been signed and was confirmed to be on file. All additional questions were answered. The patient elected
to proceed.
The patient was placed prone on the fluoroscopy table and the right lower back area was prepped and
draped in the usual sterile manner. With the aid of fluoroscopy, the right L5 foramen was identified. The skin
overlying it was anesthetized with 1% preservative-free Lidocaine solution for comfort. A 22 gauge 5 inch spinal
needle was then carefully advanced under biplanar fluoroscopic guidance into the safe triangle of the right L5
foramen. Once the tip of the needle was felt to be inside the foramen, a final lateral view was obtained to confirm
placement. A small extension tube was attached to the needle and aspiration with a syringe was performed. No
CSF or blood was noted. Injection of 1 cc of Omnipaque (Iohexol 300) contrast dye revealed typical periradicular
flow and proximal epidural spread of contrast. There was no evidence of vascular flow. Then, 2.5 cc of a 5 cc
solution consisting of 2 cc Dexamethasone (4mg/ml) with a remainder of 1% preservative-free Lidocaine were
injected without difficulty. The needle and the extension tube were withdrawn from the patient. The same
procedure was repeated for the right L4 foramen.