AHA Coding Clinic® for HCPCS - 2024 Quarter 4; Ask the Editor

Right L4-L5 facet joint cyst aspiration and intra-articular corticosteroid injection

A patient is suffering from recurrent right-sided lumbosacral lower extremity radicular pain, secondary to right-sided L4-L5 facet joint cyst causing lumbar spinal stenosis and lumbosacral radiculitis. The patient now presents for a repeat right-sided L4-L5 lumbar facet joint cyst aspiration followed by an intra-articular corticosteroid injection. The mid to lower lumbar vertebral levels were identified with fluoroscopy. The C-arm was rotated obliquely to maximize the facet joint space. A spinal needle was then advanced parallel to the X-ray beam towards the right-sided L4-L5 facet joint. Using the coaxial technique and intermittent fluoroscopy, the needle was advanced until the facet joint capsule was penetrated. One ml of serosanguineous fluid was aspirated.  Following that 0.2 ml of contrast was injected to reveal adequate spread within the facet joint capsule. There was no vascular uptake or spread of contrast into the neuraxial space. One ml of 20 mg of triamcinolone in preservative free ropivacaine 0.2% was then injected (intra-articular and periarticular) after negative aspiration for heme and CSF. All needles were flushed and withdrawn. Sterile dressings were applied to the puncture sites. The patient was discharged and there was no immediate evidence of procedure-related complications. Would it be appropriate to assign a code(s) for the facet joint cyst aspiration and the intra-articular corticosteroid injection under fluoroscopic guidance? ...

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