Overview of CPT Code 20910: Injection of Epidural Steroid
CPT Code 20910 refers to the injection of epidural steroid medication into the epidural space to relieve pain and inflammation, primarily in the lower back and legs.
When CPT Code 20910 is Used?
This procedure is indicated in various clinical scenarios.
- Chronic lower back pain due to herniated discs.
- Radicular pain (sciatica) stemming from nerve root compression.
- Spinal stenosis causing significant discomfort.
- Post-surgical pain management in the spine.
Symptoms Indicating This Procedure
Patients typically report specific symptoms that may warrant this procedure.
- Severe lower back pain that radiates to the legs.
- Numbness or tingling in the legs.
- Weakness in the lower extremities.
- Difficulty in performing daily activities due to pain.
Causes and Risk Factors
Understanding the underlying causes can help in managing the condition.
- Degenerative disc disease.
- Herniated or bulging discs.
- Spinal injuries or trauma.
- Obesity and sedentary lifestyle.
Diagnostic Tests Before Procedure
Certain tests are often conducted to confirm the need for this procedure.
- MRI of the lumbar spine to visualize disc herniation.
- CT scan for detailed imaging of spinal structures.
- X-rays to assess spinal alignment and degeneration.
- Nerve conduction studies to evaluate nerve function.
Procedure Description
The procedure is performed in a controlled environment.
- Patient is positioned comfortably, usually lying on their stomach.
- Skin is cleaned and sterilized at the injection site.
- Local anesthetic is administered to minimize discomfort.
- A needle is carefully inserted into the epidural space using fluoroscopic guidance.
- Steroid medication is injected into the epidural space.
- Needle is removed, and a bandage is applied.
Preparation for the Procedure
Patients should follow specific guidelines before the procedure.
- Avoid blood thinners for a few days prior to the procedure.
- Inform the doctor about any allergies or medications.
- Arrange for transportation home post-procedure.
- Wear comfortable clothing on the day of the procedure.
Recovery and Aftercare
Post-procedure care is essential for optimal recovery.
- Rest for the remainder of the day after the procedure.
- Apply ice to the injection site to reduce swelling.
- Avoid strenuous activities for at least 48 hours.
- Follow up with the physician as advised for reassessment.
Possible Complications
While generally safe, there are potential risks associated with the procedure.
- Infection at the injection site.
- Bleeding or hematoma formation.
- Nerve damage or worsening of symptoms.
- Allergic reaction to the steroid medication.
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Post-Procedure Follow-Up
Monitoring after the procedure is crucial for assessing effectiveness.
- Follow-up appointment within 1-2 weeks to evaluate pain relief.
- Additional imaging if symptoms persist.
- Discussion of further treatment options if necessary.
Alternative Treatments
There are several non-surgical options available.
- Physical therapy to strengthen back muscles.
- Chiropractic adjustments.
- Acupuncture for pain relief.
- Medications such as NSAIDs or muscle relaxants.
Home Care Tips
Patients can take simple steps to aid recovery at home.
- Stay hydrated and maintain a balanced diet.
- Engage in light stretching exercises as tolerated.
- Use heat therapy for muscle relaxation.
- Keep a pain diary to track symptoms and relief.
Patient Education & Prevention
Educating patients can help prevent recurrence.
- Maintain a healthy weight to reduce spinal stress.
- Practice good posture while sitting and standing.
- Engage in regular low-impact exercise.
- Avoid heavy lifting and twisting motions.
Billing and Coding Information
CPT Code: 20910
Category: Injection Procedures
Common Modifiers:
- 50 (bilateral procedure)
- RT (right side)
- LT (left side)
Average Cost and Insurance Coverage
Costs can vary based on location and insurance.
- Average cost ranges from $1,000 to $3,000.
- Most insurance plans cover the procedure if medically necessary.
- Out-of-pocket costs depend on the patient's insurance plan.
Related CPT Codes
References and Sources
Frequently Asked Questions (FAQs)
How long does the procedure take?
The injection itself usually takes about 15-30 minutes.
Will I feel pain during the injection?
You may feel some discomfort, but local anesthesia is used to minimize pain.
How soon will I feel relief?
Some patients experience relief within a few days, while others may take longer.
Can I drive after the procedure?
It is recommended to have someone drive you home after the procedure.
