Coding for SI Injections with Office Visit
A female patient previously diagnosed with sacroiliitis and ankylosing spondylitis returns to the office for a follow-up visit. The patient reports her lower back has been stiff and swollen for the past couple of weeks. She is currently on celecoxib and ranitidine, and mentions that she had some nausea after taking the celecoxib. She works full time and is a nonsmoker.
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Explore This IssueJuly 2015
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On examination, the patient is alert and oriented. She has normal vital signs. She is 5’7″ and weighs 140 lbs., and her temperature 98º. Her head, eyes, ears, nose and throat exam is normal. There is no lymphadenopathy. Her lungs are clear. Her heart is at a regular rate and rhythm, with no murmurs or friction rubs, and there are good peripheral pulses. Her abdomen is soft, non-tender, with no mass or hepatosplenomegaly. The patient’s physical examination is remarkable for a large effusion of the sacroiliac joint. The physician makes the decision to give the patient an injection via CT guidance. The physician explains therapeutic options to the patient, including risks and benefits, and performs the SI injection with 10 mg of triamcinolone acetonide to the lower back region. The patient is taken off of celecoxib. A new prescription for the pain is prescribed and the patient is given discharge instructions on post–sacroiliac injection care and follow-up.