(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3–4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3–4; normal discography L3–4.Procedure:Awake discography and injection, L3–4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3–4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.Question:What CPT® and ICD-10-CM coding is reported?)
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