8 Steps for Accurate Spinal Injection Coding & Documentation

Mary LeGrand, RN, MA, CCS-P, CPC, senior consultant with KarenZupko & Associates, recently outlined steps to make sure spinal injection are coded accurately in an AAOS Now report.

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Coders should take these steps to make sure the injection is coded accurately:
•    Pick the right primary code
•    Include secondary procedure codes if necessary
•    Chose a radiology code when appropriate
•    Consider where the surgery is performed
•    Include J codes for injectable medication when the medication expense is incurred by the practice
•    Indicate whether a catheter is being used
•    Show what type of image guidance was used — fluoroscopy or otherwise
•    Indicate the injection site

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