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.
What CPT(R) and ICD-10-CM coding is reported?