04/28/17 – Hardware Injections

Question: How should we bill for a pedicle screw injection? We had a patient come in for an injection for pain related to his right L5 pedicle screw from his previous spinal fusion. Should we use a facet injection code or an unlisted code?

Answer: The unlisted code 64999 is the correct answer. Here’s an example of how you might document the procedure: “Fluoroscopy was used to identify the appropriate hardware site L5; aspiration was negative for blood and cerebrospinal fluid: Marcaine with epinephrine was injected around the hardware.”

Please note: the fluoroscopy would be bundled into the service. You would not report the imaging code 77003 separately.

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