Steve presents today for an epidural injection of a steroid, caudal to relieve his low back pain, radiating leg pain, and coccygodynia. Steve is placed in a prone position with a cushion below his stomach to arch his back. Local anesthetic is applied to numb the skin and tissue down to the surface of the sacral hiatus. After the needle is placed in the area, 1.5cm of contrast solution helps the physician see painful areas under fluoroscope. The steroid is injected in the epidural space. The needle is removed, bandage applied, and the patient is sent home. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code is 62323 for an epidural injection of a steroid in the lumbar or sacral region. The ICD-10-CM codes are M54.5 for low back pain, M79.606 for pain in the leg, and M53.3 for coccygodynia.

Steve Presents Today for an Epidural Injection of a Steroid