AHA Coding Clinic® for HCPCS - 2012 Issue 3; Ask the Editor

Transforaminal Epidural Injection

A patient presents to have a transforaminal epidural injection for treatment of lower back and leg pain. The right L3-4, L4-5, L5-S1 neural foramen were marked for needle placement.  Under fluoroscopic-guidance utilizing the double-needle technique, a 20-gauge spinal needle was inserted anteriorly into the level of the neural foramen and the corresponding nerve root. A 25-gauge needle was then inserted through the 20-gauge introducer at the midportion of the L3-4, L4-5, and L5-S1 neural foramen. After needle placement was confirmed, and no blood or cerebral spinal fluid (CSF) was aspirated, Isovue contrast was injected. No abnormalities were noted. In the L5-S1 level a cortisone solution was injected. A Depo-Medrol, lidocaine solution was injected at the L3-4 and L4-5 levels. The patient displayed no adverse reactions and was discharged in good condition. What is the correct code(s) for the injections performed at three levels utilizing the double needle technique? ...

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