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Scenario Week of February 23, 2010:
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Case Study

Preoperative Diagnosis: Facet arthropathy and myelopathy, with facet joint mediated pain, C4–C5, C5–C6, C6–C7, bilateral

Postoperative Diagnosis: Facet arthropathy and myelopathy, with facet joint mediated pain, C4–C5, C5–C6, C6–C7, bilateral

Operation: Diagnostic facet block, medial branch technique, fluoroscopically guided at C4, C5, C6, and C7, bilateral

Anesthesia: General with local infiltration

Blood Loss: Minimal

Complications: None

The patient is a 49-year-old male with a history of “sharp grinding” neck pain for the past 5 to 6 years. The patient was involved in a shallow water diving accident in the 1980s that involved a cervical spinal cord injury with temporary paralysis. The patient did not have significant pain after the accident but developed “grinding” pain in the neck in the late 90s. He is now referred for a diagnostic facet block. The patient’s concurrent medical problems include hypertension and non-insulin-dependent diabetes mellitus, as well as gastritis and ulcer disease, probably related to alcohol abuse. The patient gives an ongoing history of alcohol abuse and has a past history of polydrug abuse. The patient’s current medications include tramadol, trazodone, and gabapentin. The patient is not allergic to any medication.

On examination today, the patient is alert, oriented, and appears in mild discomfort. Skin is intact in the posterior cervical area. The lungs are clear to auscultation. The cardiac rhythm is regular, and no extra cardiac sounds are noted.

Informed Consent
Risks of the procedure were discussed with the patient, including bleeding, infection, drug reaction, drug allergy, and the patient wished to proceed.

Approach and Surgical Procedure
The patient was transported to the operating room and placed in the prone position, with a pillow under the chest wall and a neurosurgical support under the forehead. The skin over the posterior cervical area was sterilely prepped and draped in the usual manner. Skin anesthesia was produced over the midportion of the lateral extent of bodies of C4, C5, C6, and C7 on each side with 0.2 ml of 0.5% lidocaine.

Deep anesthesia was produced in each location with an additional 0.25 ml of 0.5% lidocaine utilizing a 25- gauge, 1-inch needle.

In each location, a 22- gauge 3-inch Quincke point spinal needle was introduced and fluoroscopically guided to contact the lateral extent of the midportion of the vertebral bodies, C4, C5, C6, and C7 on the right and left sides. Each needle location was confirmed by fluoroscopy in the AP and lateral views.

No needle location encroached on any neural foramen. No cerebral spinal fluid or blood was aspirated, and no paresthesias were elicited.

Next, 0.3 ml of a 50/50 mixture of 2% lidocaine and 0.5% bupivacaine with 5 mg of Depo-Medrol per 3 ml of total solution was injected at each needle location.

The patient tolerated the procedure well. The patient was returned to the recovery area in satisfactory condition. The patient noted almost instantaneous significant improvement in the pain in his neck, although he continued to note the “grinding” sensation. The patient will be seen in one week in follow-up.

Please assign the correct CPT and ICD-9-CM codes for the procedure above.

CPT Answers

64490Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)
64492Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

New codes were added in 2010 to report paravertebral facet injections. Coders should carefully read the code description and instructional text contained in CPT. Codes 64490-64495 are used to report both diagnostic and therapeutic injections. The actual medication injected is not used to select a specific code. The codes are reported per level treated, regardless of the number of injections provided on each level. In addition, these services now include the use of fluoroscopic or CT guidance. According to CPT Changes 2010 – An Insider’s View, “imaging guidance and localization are required for the performance of paravertebral facet joint or nerve injections.” The imaging services as well as all injections are included in the code representing the level treated.

It is important to note that 64490 is reported for the first level treated and 64491 for the second level treated. If three or more levels are treated then 64492 is reported once in addition to 64490 and 64491. Thus in the example cited above 64490, 64491, and 64492 are each reported once. This is the maximum number of codes reported even if more cervical or thoracic levels were treated at this session.

Additional guidance in CPT states that if T12–L1 is treated, it is reported with the codes for the lumbar and sacral injections rather than 64490–64492 that are used to report cervical or thoracic injections.

CPT errata should be referenced if ultrasound guidance is used to perform the paravertebral injections. The errata states that Category III codes 0213T–0215T should be used to report cervical and thoracic injections and 0216T–0218T for lumbar or sacral injections using ultrasound guidance.

Prior to 2010, codes 64470–64476 were used to report paravertebral facet injections and fluoroscopic or CT guidance was separately reported. These codes were deleted for 2010. For injections that do not utilize imaging guidance, CPT guidelines for 64490–64495 indicate codes 20550–20553 should be reported.

It should also be noted that the re-evaluation of the patient prior to a scheduled procedure is part of the procedure. The physician has a responsibility to verify that the patient is still a good candidate for the procedure and that there are no contraindications. Local anesthesia or contrast injections are also included in the procedure codes.

ICD-9-CM Answers

721.1 Cervical spondylosis with myelopathy
401.9 Unspecified essential hypertension
250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
535.50 Unspecified gastritis and gastroduodenitis without mention of hemorrhage
305.00 Nondependent alcohol abuse, unspecified drunkenness

The first listed or primary diagnosis is the cervical spondylosis with myelopathy. This is the reason the patient is seeking treatment. Although this diagnosis can be applied to more than one site, it is reported only once per encounter.

For physician services, other diagnoses that may affect the patient are also listed. The patient’s hypertension should be monitored before, during, and after the procedure and could have compromised the performance of the procedure. The patient’s diabetic status may also complicate the presence of the myelopathy and may contribute to ongoing myelopathy and needed to be ruled out as a source of the patient’s current condition. Certain medications can affect the digestive system and need to be evaluated when prescribing medication including oral and injectable drugs. Lastly, the patient’s sensitivity to medications may be compromised by the history of alcohol abuse.

Coding guidelines for physician services indicate that other diagnoses that may affect the treatment of the patient’s condition should also be reported.

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