tci Outpatient Facility Coding Alert - 2013 Issue 1

Reader Question: Documentation Is Crucial to Reporting Bilateral Injections

Question: One of the pain management specialists submitted the following documentation: "Utilizing fluoroscopic guidance in the vertical plane, we were able to appreciate the pedicle, bilateral L4-L5. The skin was anesthetized superficially and deeply utilizing lidocaine 1% without epinephrine or preservatives in a 25-gauge 1-1/2-inch needle. A 23-gauge spinal needle was advanced to the 6 o’ clock position of the pedicle entering the superior aspect of the neural foramen. In the oblique plane of view, the needle was moved into a more anterior position inferior to the pedicle. The needle was in the most superior aspect of the neural...

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