AMA Clinical Examples in Radiology - 2018 Issue 1 (Winter)
CT-guided Lumbar Transforaminal Epidural Injection
CLINICAL EXAMPLE 2 CT-guided Lumbar Transforaminal Epidural Injection CLINICAL HISTORY Bilateral intervertebral disc displacement L1-L2 TECHNIQUE Informed consent was obtained. The patient has had L1 nerve root blocks, the most recent on the left side 6 months ago. She obtained good pain relief, but symptoms have returned. Also, she had an L2-L4 fusion. Advanced degenerative changes are seen at the L1-L2 level with foraminal and canal stenosis. 64483 With the patient in the prone position, axial 2.5-mm computed tomography (CT) images were obtained to localize the L1 foramina. Under sterile conditions and following local anesthesia with 1% lidocaine...
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Article Overview
This article presents a clinical example of a CT-guided lumbar transforaminal epidural injection and discusses how the service is represented in procedural and diagnosis coding. It is useful for coders, billing staff, radiology practices, and pain management teams who need to understand the broader coding framework, associated diagnosis categories, and when related imaging guidance codes are or are not referenced. The article also touches on bilateral procedure reporting, ultrasound-related alternatives, and the role of guidance codes in the surrounding coding guidance.
Why This Topic Matters
The article helps readers place a common spine intervention into the correct coding context and understand how adjacent guidance and diagnosis concepts are addressed in the source material. It is especially relevant for avoiding mismatches between the procedure performed, the diagnosis documented, and the imaging guidance referenced in coding guidance.
Article Sections
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Clinical Example 2
A case-based example describing the clinical context and procedural setting for a lumbar transforaminal epidural injection.
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How to Code
A coding summary section that presents the associated procedure and diagnosis coding references and indicates related reporting considerations.
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Discussion
Expanded discussion of the coding framework, including related CPT, ICD-10-CM, Category III, and HCPCS Level II references and the surrounding imaging guidance context.
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Sources
Citations to the reference materials and publication sources used for the clinical example and discussion.
What You Will Learn
- How the article frames a CT-guided lumbar transforaminal epidural injection in a coding context
- Which code sets are referenced in the discussion of the procedure and diagnoses
- How the article situates related imaging guidance references and bilateral reporting concepts
- What types of source materials underpin the clinical example and commentary
Who Should Read This
- Medical coders
- Billing specialists
- Radiology coders
- Pain management practices
- Revenue cycle staff
- Compliance teams
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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