Title: Coding Consultation: Questions and Answers
Surgery: Nervous System
Question:Fluoroscopy was used to identify the appropriate hardware sites at L4, L5, and S1; aspiration was negative for blood and cerebrospinal fluid; and Marcaine with epinephrine was injected around the hardware. What is the appropriate CPT code to report for the injections around the hardware with fluoroscopy?
Answer:This procedure is reported with the unlisted code 64999,Unlisted procedure, nervous system, as there is no CPT code that describes this service. When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, the procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service.
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