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Nerve root injection without mention of transforaminal approach.

Date: Aug 18, 2023

Question:

Please help! Should this be coded with 64479 or 62321? "1% lidocaine was used for local anesthesia. Under CT guidance, a 22-gauge needle was advanced to lie with its tip adjacent to the verve root. Appropriate needle position was confirmed with CT imaging and injection of myelographic contrast. A mixture containing 0.5 mL of 0.25% bupivacaine, and 10 mg of dexamethasone was then administered in and around the nerve root. the needle was then withdrawn. Pre-procedure pain score; 7. Post procedure pain score: 2. Successful CT-guided right C5 selective nerve root injection." The indication is for Foraminal stenosis of C-spine, radicular pain of RT upper extremity. Pt is S/P C-spine fusion (order does not specify the level of fusion). The facility is reporting 64479. The coder wants this changed to 62321 because there is no documentation of transforaminal. Do codes 64479-64484 require documentation of transforaminal? How should this be reported? Thank you!

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