Vol. 13 •Issue 22 • Page 12
Coding Nervous System Procedures
Case Study 1
Preoperative Diagnosis: Upper back pain
Postoperative Diagnosis: Upper back pain
Procedure Performed:.Thoracic T5 epidural neurolysis
Anesthesia: 2% lidocaine
Indications: The patient was evaluated in the emergency room. He had previous lumbar injections x 2 with improvement, but pain returned after a short period. Last time he was given a trigger point injection into the paraspinous muscles on the right with good recovery but still complains of midline back pain. He was informed of the risks and complications of having this block done and agreed to proceed.
Operative Technique: The patient was placed in the sitting position. His back was prepped and draped in a sterile fashion and anesthetized with 2% lidocaine. The epidural needle advanced easily into the epidural space using a loss of resistance technique.
At this point a total volume of 0.5 cc of 2% lidocaine was injected without any problems. An epidural catheter was inserted and again 0.5 cc of lidocaine was injected without any difficulty after aspiration. Then a total volume of 1.75 cc of 6% phenol was injected through the catheter with the patient in a 30% upright position.
The patient then was allowed to remain in the emergency room for approximately a half hour. He was re-evaluated and his paraspinous muscle had relaxed, and the pain was gone in his upper back, and also in two small areas. He still has some right lower rib pain from a previous fracture, but the predominant pain of the mid back was gone. He was discharged in satisfactory condition and will follow up with phone call in two days to evaluate therapy.
Code Assignments and Rationale
As stated above, the physician performed a thoracic T5 epidural neurolysis. When you look in the index under the terms Neurolysis, Nerve, you are directed to codes 64704-64708. A review of these codes shows that they refer to a neuroplasty of digits or the nerve of the hand and foot and are not appropriate for the procedure that’s been performed. The term Internal is indented under Neurolysis, Nerve. The code for this term is 64727—an add-on code that refers to the use of an operating microscope during the procedure.
However, as indicated in the above operative report, the physician performed an “epidural” injection. Looking in the CPT manual index under the term Epidural, Injection, you will see the following code ranges listed: 62281Ð62282, 62310Ð62319, 64479Ð64484. After checking the descriptors for these codes, you will see that the following code is the correct one for both facility and professional components.
62281 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic
This area of coding is confusing to most coders because of the approaches.
Because the operative report lists “upper back pain” as both the preoperative and postoperative diagnosis, the following ICD-9-CM code would be assigned for both.
724.5 Backache, unspecified
Case Study 2
Preoperative Diagnosis: Intractable mechanical left leg pain
Postoperative Diagnosis: Intractable mechanical left leg pain
Procedure Performed: Lumbar epidural steroid injection
Operative Technique: After informed consent, the patient was placed in a sitting position. The lumbar region was sterilely prepped with Betadine. The L1-L2 interspace was identified, and a subcutaneous injection of 1.5% lidocaine with 25-gauge needle was done prior to insertion of an 18-gauge needle with further infiltration into the interspinous ligament with 1.5% lidocaine for a total volume of 6 cc being injected in this manner.
A 17-gauge Tuohy needle was then inserted and guided in the middle, using loss-of-resistance technique to the epidural space. Upon loss of resistance to air, a mixture of 11 cc of 0.5% lidocaine with 80 mg Aristocort was made. This was injected after a negative aspiration. Following the injection, a further volume of 2 cc of 1.5% lidocaine was injected through the needle as it was pulled through the ligamentous structures in the back.
The needle was withdrawn in this manner, and the patient was then placed in a supine, head-of-bed-up-30-degrees position, after placement of a sterile Band-Aid. The patient was allowed to stay in this position for 20 minutes, and the patient reported good relief of the left leg pain that was present prior to the injection being done. No complications were noted.
Code Assignments and Rationale
To arrive at the most appropriate CPT code for this procedure, go to the term Epidural in the index. Because an epidural injection was performed, you would check under the term Injection where you would find the following codes listed: 62281-62282, 62310-62319, 64479-64484.
A clue to which code you choose lies in the fact that the physician performed an epidural injection of the lumbar area. After reading the descriptors for these codes, you will see that the following is the correct choice for both the facility and professional components.
62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)
Note that the lidocaine mixed with the steroid is included in procedure code 62311, so no additional code is needed.
Because the operative report lists “intractable mechanical left leg pain” as both the preoperative and postoperative diagnosis, the following ICD-9-CM code would be assigned for both.
729.5 Pain in limb
Kathleen A. Mundy is manager of consulting services, physician division, with Medical Learning (MedLearn®), St. Paul, MN.