icd10 coding

Appendix Additional Practice Exercises 3 urgical Case #58 perative Diagnosis edure(s) Performed ications for Procedure: Details of Procedure: Operative Report 1. Backache, unspecified 2. Related back and leg pain Lumbar epidural steroid injection L5-S1 interspace The patient is a 41-year-old man with severe work- related back and leg pain, more left than right. The patient understands the sens for the procedure and the risk associated with it. The patient is anxious and needed IV sedation, he tolerated the pain associated with injection For the procedure, the patient was placed prone on the fluoroscopy table with a pillow under his abdo- men. We identified the sacral hiatus. We prepared the skin with alcohol and DuraPrep and applied drapes and anesthetined the skin with xylocaine. Next, we used fluoroscopy to guide the 17-gauge needle into the spinal canal through the sacral hiatus This was advanced under AP and lateral fluoroscopic guidance with loss of resistance. We verified proper depth and placement with myelography injection The lumbar myelography injection was extradural in the lumbosacral area and consisted of 2 cc of Iso- vue 300. This showed we were in the spinal canal and highlighting the nerve roots at the lumbosacral region. Next, we placed the catheter to the L5-S1 interspace. Through the catheter we injected steroid solution that contained 80 mg of Depo-Medrol, 3 cc of 075% Mar- caine, and 4 cc of Omnipaque 300. This was injected under fluoroscopy, visualizing the nerve roots well throughout the lower lumbar area, more left than right. We cleared the catheter and needle of solution and removed them from the back. Permanent films were taken, and the patient was taken to the recovery room where he recovered in good condition Interpretation of Permanent Films The permanent films afterward verified the myelog raphy and steroid solution were in the proper areas. On AP and lateral views, the solution highlighted the nerve roots at the lower lumbar area but scar tissue is preventing the spread of medication throughout the entire region. Nerve roots do highlight in the lower lumbar spine. No evidence of dural puncture Code(s)