Diagnosis Lumbosacral Spondylosis Question & Answer Guide (With Explanation)

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Original Question

Diagnosis: Lumbosacral spondylosis without myelopathy. Procedure Performed: Radiofrequency thermocoagulation neurolysis of medial branches, posterior primary rami, L2-L3, L3-L4, L4-L5, and superior branch, posterior primary ramus, L5-S1, fluoroscopic guidance. Right Side: Heplock was placed and patient was given 1 mg of versed. The patient was placed in the prone position on the fluoroscopy table. The skin over the right lumbosacral spine was prepped with Betadine and sterilely draped. The appropriate vertebral levels were identified fluoroscopically. Using oblique fluoroscopy, the target sites for the lumbar medial branches were identified as the ipsilateral junctions of the superior border of the transverse process and the lateral border of the respective superior articulating process. For the S1 superior branch. It was the superior rim of the posterior opening of the posterior S1 neuroforamin. The overlying skin at each site was anesthetized with lidocaine. The procedure was performed with a 100 mm Insulated 22-gauge stimulating needle with a 10 mm active tip. After inserting the electrode, the tip of the needle was manipulated slightly to achieve concordant sensation with less than 1-volt threshold stimulation at 50 hertz to determine eligibility for lesioning. All of the above sites passed this sensory stimulation test. This was followed by motor stimulation at 2 hertz and 2 volts at each eligible site, which produced no buttock or lower extremity muscle twitching. After passing these 2 criteria, the electrode was removed and each eligible site was anesthetized with 0.75 cc of a mixture of 5 cc 1.0 % preservative free plain lidocaine mixed with 20 mg of Kenalog (Triamcinolone Acetonide), and 90 seconds were allowed to pass. The electrode was then reinserted, and lesioning begun at 80 degrees centigrade and continued for 60 seconds. The electrode-needle complex was then removed There were no complications. The patient was observed in the recovery room for at least 30 minutes during which time vital signs remained stable. The patient’s response to the procedure was recorded in the chart. The patient was instructed as to possible post procedure discomfort resulting from burn lesions in immediately adjacent tissues and was discharged in stable condition to return al the next scheduled appointment for follow up. What are the CPT® and ICD-10-CM codes reported?

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