Radiology Test Case: Epidural Steroid Injection

RADIOLOGY TEST CASE The radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Consider your answers as to how the procedure is reported in 2016. Once you are confident with your answer, turn to page 12 for the correct answer and discussion. Epidural Steroid Injection CLINICAL HISTORY Low back pain, lumbar degenerative disc disease, lumbar spinal stenosis. PROCEDURE Epidural steroid injection, L4-L5. TECHNIQUE Informed consent was obtained and the patient was placed prone on the fluoroscopy table. Using sterile technique, local anesthesia, and fluoroscopic guidance, a...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article presents a radiology coding test case focused on a lumbar epidural steroid injection and the associated imaging documentation. It is intended for coding professionals who want to assess how the encounter is documented in the context of 2016 reporting guidance. The content centers on procedural narrative, fluoroscopic guidance, contrast use, and the discussion of the case answer.

Why This Topic Matters

It helps radiology coding professionals determine whether the full case discussion is relevant to their work, especially when reviewing documentation patterns for image-guided spine procedures.

Article Sections

  1. Radiology Test Case

    Introduces the coding practice case and frames it as a review exercise for radiology professionals.

  2. Epidural Steroid Injection

    Presents the clinical context, procedural documentation, imaging guidance, and post-procedure impression for the case.

What You Will Learn

  • How a radiology test case is structured for coding review
  • What types of procedural documentation are included in an image-guided spine injection case
  • Which general imaging and procedural elements are discussed in the case narrative
  • How the article is positioned in relation to 2016 reporting

Who Should Read This

  • Radiology coders
  • Coding auditors
  • Radiology billing staff
  • Coding educators
  • Documentation specialists

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