Discharged from recovery in satisfactory condition

Reference no: EM133667903

Question

What ICD-10-CM, CPT, and APC codes should be reported for this case study? Patient injured his lower back lifting a patient on May 15 of this past year and diagnosed with right L3-4 radiculopathy, with secondary myofascial pain in the right lower lumbar paraspinal muscles. He was treated with physical therapy, pain medication, and a TENS unit. Patient states that he still experiences occasional pain even after this treatment. Previous lumbar myelogram showed mild spinal stenosis at L4-L5 and a CT of the lumbar spine showed mild to moderate acquired spinal stenosis at L4-L5. Patient was prepped and epidural (caudal) therapeutic block administered at L4-L5. The procedure was well tolerated, and the patient was discharged from recovery in satisfactory condition to follow up in the office next week. He was instructed to do no lifting the first week post-procedure, and is restricted to no more than 25 pounds thereafter.

Reference no: EM133667903

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