Preprоcedure diаgnоsis: Lumbаr rаdiculоpathy Postprocedure diagnosis: Lumbar radiculopathy Procedure performed: Lumbar epidural steroid injection Anesthesia given: Local Indications for procedure: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections. Description of procedure: The patient was placed in the left lateral decubitus position. The L4–5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo-Medrol 80 mg, normal saline 10 cc, and lidocaine 1% at 5 cc was injected. No complications were encountered, and the patient was returned to the outpatient surgery department in stable condition. Plan: To repeat this procedure in two weeks Select the appropriate ICD-10-CM and CPT code(s):
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