In this assignment, students will review the procedure note below.
DIAGNOSIS: Low back pain—internal disk derangement
PROCEDURE: Lumbar epidural steroid injection, L5-S1
ANESTHESIA: Local with intravenous sedation
TECHNIQUE: In the prone position, under fluoroscopic guidance with Betadine skin prep and aseptic technique, using 2 mL of 1 percent lidocaine for the skin at the L5-S1 level, epidural was done with the loss of resistance technique. The position of the needle was confirmed under fluoroscopy on AP and lateral views. There was no paresthesia. No blood or cerebrospinal fluid on aspiration. 3 mL of 1:200 concentration Isovue was injected and the flow of contrast was found to be in the posterior epidural space. 3 mL of 1 percent preservative-free lidocaine was injected and there were no sensory/motor changes in either extremity. 40 mg of Kenalog mixed with 3 mL of preservative-free normal saline was injected. The patient tolerated the procedure well.
What is the main term used to code the diagnosis?
What root operation(s) should be used to describe the procedure?
What code(s) should be assigned?