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A 37-year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5-S1, the physician uses the transforaminal approach under fluoroscopy guidance for needle positioning. The spinal needle is inserted, and the patient experiences paresthesias in her left lower extremity. The anesthetic drug is injected into the epidural space.

What CPT® code(s) is/are reported?

A. 62320
B. 62322
C. 62323
D. 62327

Answer :

Final answer:

The appropriate CPT code for the described epidural injection at the L5-S1 level with the transforaminal approach and fluoroscopy guidance is 62323.

Explanation:

The correct Current Procedural Terminology (CPT) code for an epidural injection using the transforaminal approach under fluoroscopy guidance at the L5-S1 level is 62323. This code represents the injection of a diagnostic or therapeutic substance into the epidural space of the spine using imaging guidance, which in this case is fluoroscopy, and includes the associated neurolytic agent administration. The paresthesias experienced by the patient during the procedure suggest accurate needle positioning in the vicinity of the nerve roots, which is typical during a transforaminal epidural injection. It is crucial for the physician to monitor the patient's feedback to adjust the needle placement and ensure the safe and effective delivery of the anesthetic drug.

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