Can anyone advise as to whether it is appropriate to code 64493-77002 along with a cyst aspiration 10160-77002 at the same site? Dictation is below...any input would be great....thanks in advance!
HISTORY: 59-year-old female with worsening low back pain and left leg
pain. Recent outside MRI demonstrated a prominent synovial cyst
projecting medially off of the left L3-L4 facet joint. Patient is
referred now for cyst aspiration and facet block.
Intravenous fentanyl was utilized for today's surgery.
After obtaining informed consent patient's lower back was sterilely
prepped and draped. Local and deep periarticular anesthetic was
applied. A 14-gauge crown needle was then hammered into the left L3-L4
facet joint under continuous fluoroscopic guidance. Once the needle
was appropriately positioned, a facet arthrogram was performed to
document good intra-articular positioning. There was also noted to be
communicating with a saccular recess extending into the spinal canal
consistent with the recent MRI findings. Aggressive manual aspiration
was then performed with removal of 1 to 2 cc of clear synovial fluid.
A second 14-gauge needle was then advanced down into the facet joint
utilizing similar techniques. Aggressive manual capsular disruption
was then performed utilizing these two stiff needles. The facet joint
was irrigated with several cc of Marcaine an approximately 1 cc of
Depo-Medrol was instilled intra and extra-articularly at this site.
The needles were removed and patient left radiology in stable
IMPRESSION: Uncomplicated left L3-L4 synovial cyst aspiration, facet
block and capsular disruption is performed as described above.
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