To Whom It May Concern,

I need some help with a Pain Management procedure. What key words do I need to look for in a procedure note to differentiate between a Lumbar Interlaminar ESI Injection (CPT 62323) and a Lumbar Transforaminal ESI Injection (CPT 64483) so it can be coded accurately?

Below is the providers procedure note for review:

Procedure: Lumbar Epidural Steroid Injection under fluoroscopy.
Diagnosis: Lumbar Degenerative Disc Disease

The patient was evaluated and the procedure risks, benefits and alternatives were discussed with the patient. Informed consent was then obtained.
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The patient was taken into the procedure room and was placed prone on the table. Skin was prepped with chloraprep and draped in a sterile manner. Sterile technique was observed throughout the procedure. Fluoroscopy was used to identify the targeted L4-5 L5-S1 interspace. Using a 25 gauge needle 5cc of 1% lidocaine was used to achieve adequate local anesthesia.

A 20 gauge epidural needle was advanced into the epidural space under fluoroscopic guidance utilizing the loss or resistance technique[/COLOR][/COLOR]. No parasthesias were noted. After negative aspiration 1 ml of 300 omnipaque was injected. Contrast was confirmed in the epidural space via fluoroscopy. Methylprednisolone [ ] mg mixed with [ ] ml normal saline was slowly injected. The needle was removed intact. The patient remained awake and communicative throughout the procedure with no complaints of pain on injection.

The patient received 50-60% relief from this procedure.

The patient tolerated the procedure well and was transferred to the recovery area without complication and was discharged home after remaining stable during observation.

Appreciate your help.
Thank you.
Lauren