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Thread: Cervical epi steroid injection under fluoroscopy

  1. #1

    Default Cervical epi steroid injection under fluoroscopy

    AAPC: Back to School
    Hi all - I really need some help on coding this one as I am in the dark.
    P.S. Procedure was done on 12/4/09

    Diagnosis: Cervical spine pain

    Procedure: Cervical epidural steroid injection under fluoroscopy

    Description: After sterile triple Betadine prep and drape, appropriate positioning and fluoroscopic evaluation, the L4-L5 level was identified. Marcaine 0.25% with epinephrine was injected in the subdermal space, followed by placement of a Tuohy catheter. Utilizing a loss of resistance technique and under fluoroscopic visualization, the epidural space was identified. Aspiration for blood and CSF was negative.

    Contrast was injected, 1cc, and the epidural space was identified. This was followed by injection of 2cc of steroid and 5cc of sterile saline and 1cc of 1% lidocaine, all without preservative, into the epidural space. The patient tolerated this well and the catheter was removed.

    The paraspinal facet spaces were identified and under fluoroscopic visualization 0.5cc of corticosteroid and 0.5cc of lidocaine was injected into the facets for a facet block on the right and left side.

  2. #2


    Was this a lumbar injection?
    It is saying that L4 & L5 levels. That is lumbar.

    I would code the epidural 62311 &77003

    Hope this helps.

  3. #3


    Thanks for catching that - it was cervical, the l4 and l5 were typos in the doc's dictation which i need to have corrected. I did use those codes though except for cervical and not lumbar. He did the l and r side of the spine and we originally billed w/lt and rt modifiers which i believe is what caused it to deny. I found out from researching today that i needed to use the modifier 50 for bilat and i am rebilling. Thanks a lot for your input.

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