Results 1 to 2 of 2

Help! Hardware Injection

  1. #1
    Default Help! Hardware Injection
    Medical Coding Books
    Hello,

    Can someone give me guidance in coding this procedure. I was thinking 64999 but it was done at 3 levels.

    PROCEDURE: BILATERAL HARDWARE INJECTION

    DIAGNOSIS: 722.52 - Intervertebral Disc Degeneration Lumbar, 724.8 - Back Symptoms Other, 722.83 - Postlaminectomy Syndrome Lumbar Region
    INDICATIONS: Back pain
    ANESTHESIA: Local/Conscious sedation

    DESCRIPTION OF PROCEDURE: With written informed consent from the patient,risk and benefits were discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient was then brought to the operating room and with appropriate monitors in place, the patient was placed prone on the fluoroscopic table. The area of the low back on the Bilateral side was prepped with Betadine and draped in a sterile fashion. Utilizing fluoroscopic guidance, the pedicle was visualized at the junction of the transverse process where the patient had a previous surgery on oblique view. Skin wheals were raised at L2, L3 and L4 , using 2 mL of 1% Lidocaine at each. Two 22 gauge 3.5 inch spinal needles were passed through the skin wheals and directed toward these structures. Once bone was contacted at the levels, needle position was checked using both PA and cross table lateral view to be sure needle tip is in proper position. Once this was seen as satisfactory and after careful aspiration reveals no blood or CSF, a mixture of 5 mL of 0.25% Marcaine and 1 mL of 40mg/mL Kenalog and 6mL of 1% Lidocaine was injected through each of the needles. The needles were removed. The puncture wound was dressed. The patient was removed from the procedure table in stable condition and brought to the recovery area, having tolerated the procedure well.


    Any help is greatly appreciated.

    Melissa Harris, CPC

  2. #2
    Default
    Below is from AMA CPT Assistant

    May 2012 page 14

    Frequently Asked Questions:Surgery: Nervous System

    Question: What code(s) may be reported for injection of 0.5% Marcaine and 80 mg of Depo-Medrol to existing spinal hardware (eg, pedicle screws) at L4, L5, and S1 bilaterally? May code 64483 be reported?

    Answer: No. Code 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level, represents transforaminal epidural nerve root injection performed in the lumbar region. There is no specific CPT code for the injection of spinal hardware. CPT code 64999, Unlisted procedure, nervous system, would be most appropriate to describe the injections for pain performed outside the foramen, as indicated in the clinical scenario provided in this inquiry. Although three spinal level (L4, L5, S1 bilaterally) injections were performed, code 64999 should be reported only once to represent the multiple injections.

Similar Threads

  1. Hardware Injection
    By Melissa Harris CPC in forum Anesthesia
    Replies: 1
    Last Post: 08-12-2015, 11:42 PM
  2. hardware injection
    By paula f3 in forum Anesthesia
    Replies: 1
    Last Post: 04-08-2013, 09:36 PM
  3. Hardware injection
    By cyclingjunkie in forum Anesthesia
    Replies: 1
    Last Post: 10-25-2012, 06:00 AM
  4. hardware injection
    By vjefcoats in forum Anesthesia
    Replies: 2
    Last Post: 04-16-2010, 01:32 PM
  5. hardware injection - coding a lumbar hardware
    By vjefcoats in forum Anesthesia
    Replies: 2
    Last Post: 04-16-2010, 09:19 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.