Preprocedure diagnosis: Lumbar radiculopathy
Postprocedure diagnosis: Lumbar radiculopathy
Procedure performed: Lumbar epidural steroid injection
Anesthesia given: Local
Indications for procedure: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections.
Description of procedure: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo-Medrol 80 mg, normal saline 10 cc, and lidocaine 1% at 5 cc was injected. No complications were encountered, and the patient was returned to the outpatient surgery department in stable condition.
Plan: To repeat this procedure in two weeks
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM code for lumbar radiculopathy is M54.16. The CPT code 62322 is appropriate for a lumbar epidural steroid injection with imaging guidance, which matches the procedure described.

Preprocedure Diagnosis: Lumbar Radiculopathy