Can someone please advise how they would code this? Dextrose was used, which implies Prolo (M0076) for both the ligament and the paraspinal injections. I have never heard of a paraspinal neurotherapy injection before. Any help would be great.
Thank you!
Joint/Spine Injection:
Injection # 2
After discussion of the risks and benefits, the patient elected to proceed with the ligament and subdermal/subcutaneous tissue injection into the bilateral thoracic back. Informed consent was obtained. Confirmed that the patient does not have history of prior adverse reactions, active infections, or relevant allergies. There was no effusion, erythema, or warmth, and the skin was clear.
The skin was prepped in a sterile fashion with Chloraprep. Local anesthetic was introduced into the area of the injection site’s using 27g 1.5 in needle 5 ml 1% lidocaine/8.4% sodium bicarbonate 10:1 mixture.
The site’s were injected with diluted 1% lidocaine and 25% dextrose as follows:
Bilateral Thoracic facet capsular ligaments of T7-8, T8-9, T9-10, T10-11. 10ml.
Neurotherapy was then performed with a 27g 1.5in needle and 15ml of 5% dextrose solution and 1% lidocaine to the thoracic paraspinalis of T7, T8, T9, T10, T11, T12.
Total volume 30ml
Patient demonstrated that they were stable before being allowed to leave the facility. The patient tolerated the procedure without complication. The patient will call immediately with any signs of infection, fever or allergic reaction. Patient instructed to keep area clean, dry and covered, avoid anti-inflammatories (e.g. Advil, Aleve, Ibuprofen), also avoid use of ice, apply heat to injection site intermittently 24-48 hours.
The patient to return as instructed.