X-ray generator: The X-ray generator delivers the electrical power to energize the X-ray tube and permits the selection of X-ray energy, X-ray quantity, and exposure time.
X-ray tube: It converts electrical energy from the X-ray generator to a X-ray beam. It is the source of radiation.
Collimator: It contains shutter blades that define the shape of the X-ray beam. Collimating the beam, or “coning down”, results in less scatter X-ray beams and therefore a sharper image. It also reduces the overall radiation dose.
Patient table and pad: It is usually made from a carbon fiber composite material to minimize X-ray attenuation. Thin foam pads are better than thick gel pads.
Image intensifier: It converts the X-ray spectrum transmitted through the patient into a highly visible image and amplifies image brightness.
Tilt versus Oblique Rotation
- All movements of the C-arm are in relation to the image intensifier.
- Cephalad/cephalic tilt: >C-arm angled to the patient's head
- Caudate/caudal tilt: >C-arm angled to the patient's feet
Fig. 1.2: The C-arm. The tube emits X-rays beams that penetrate the patient's body. The image intensifier converts the X-rays into a visible image that is then displayed on the image monitor. Distance, time, and shielding are the three most important basic guides for radiation safety. Radiation dose varies inversely to the square of the distance from the source. Always take a step back before you take a shot.
- Ipsilateral oblique rotation: >C-arm rotated toward the side of the injection
- Contralateral oblique rotation: >C-arm rotated toward the opposite side of the injection.
Anteroposterior versus Lateral
- Anteroposterior (AP) view (different at each level based upon positioning, scoliosis, lordosis, etc.):
- The spinous process is equidistant from both the pedicles
- The vertebral body endplates are horizontal lines and not oval-shaped
- AP versus PA (posteroanterior): Based upon X-ray tube. Using a C-arm, AP view are obtained when a patient is in the prone position (patient laying on the abdomen) versus PA view patients are supine (patient on their back).
- Not necessarily at 0° from angulation.
- Lateral view:
- Oblique 90° from a true AP view.
STANDARD SET UP (FIG. 1.3)
- Sterile gloves, mask, and scrub cap
- One Prep tray
- Four absorbent towel/fenestrated drape
- Chlorhexidine gluconate (ChloraPrep) or isopropyl alcohol for preoperative skin prep
- One 18–20 G × 3.5 inch Tuohy epidural needle or one 22 G 5-inch spinal needle
- Two 4 inch × 4 inch gauze dressings
- One 3 cc Luer lock syringes—contrast media
- One 10 cc Luer lock syringe—local anesthetic transdermal infiltration
- One 10 mL LOR syringe with Luer slip tip [if an interlaminar epidural steroid injection (ESI) is performed]
- One 18 G × 1.5 inch needle—aspiration needle
- One 25 G × 1.5 inch needle—transdermal infiltration needle
- Extension tubing (minimizes needle movements and increases distance from radiation exposure)
- One set of 10 medication labels
The Needle (FIG. 1.4)
- Quincke type (cutting) needle
- 22 G 5-inch spinal needle:
- May require less frequent adjustment compared to a 25 G
- 5 inch versus 3.5 inch:
- Do not find yourself short. A 5-inch needle can be used for about 90% of the blocks. Body habitus (BMI >30), oblique angulation, and block selection will determine the required length of the needle.
- Estimation of skin to the subarachnoid space depth (SSD) can be measured using Stocker's formula: SSD (mm) = 0.5 × weight (kg) + 182
- Distance taken from mid spinal level:
- The needle moves in the direction of the bevel or opposite to the notch.
- Place a 5–10° bend away from the notch to improve steerability
- Needle driving:
- Needle driving skills come with experience. When first starting off, identify your target and place the C-arm laser aimer (if available) at the center of your target. Then, “light at the center of the hub!” Place the X-ray laser marker over the hub. This technique helps keep the needle aligned to the target producing a “gun barrel” view.
PAIN PROCEDURE CURRENT PROCEDURE TERMINOLOGY CODES (2017)3
Craniofacial Blocks (Fluoroscopy is not Bundled)
- Trigeminal nerve (any branch): 64400
- Sphenopalatine ganglion: 64505
Sympathetic Blocks (Fluoroscopy is not Bundled)
- Stellate ganglion (cervical sympathetic): 64510
- Superior hypogastric plexus: 64517
- Thoracic or lumbar paravertebral sympathetic [lumbar sympathetic block (LSB)] or ganglion impar block: 64520
- Celiac plexus: 64530
- Splanchnic nerve block: 64530
Peripheral Nerve Blocks (Fluoroscopy is not Bundled)
- Other peripheral nerve: 64450
- Destruction: 64640
- Pudendal nerve block: 64430
- Intercostal nerve (single): 64420
- Intercostal nerve (multiple): 64421
- Coccygeal nerve block: 64450
Interlaminar Epidural Steroid Injections (Fluoroscopy is Bundled)
- Interlaminar—cervical or thoracic: 62321
- Interlaminar—lumbar or sacral (caudal): 62323
- Epidural blood patch: 62273
Transforaminal Epidural Steroid Injection (Fluoroscopy is Bundled)
- Transforaminal—cervical or thoracic (first level): 64479
- Transforaminal—lumbar or sacral (first level): 64483
- Transforaminal—lumbar or sacral (each additional level): 64484
Intra-articular Facet Joint or Medial Branch Block (Fluoroscopy is Bundled)
- Intra-articular joint or medial branch block (MBB)—cervical or thoracic (first level): 64490
- Intra-articular joint or MBB—cervical or thoracic (second level): 64491
- Intra-articular joint or MBB—cervical or thoracic (third level): 64492
- Intra-articular joint or MBB—lumbar or sacral (first level): 64493
- Intra-articular joint or MBB—lumbar or sacral (second level): 64494
- Intra-articular joint or MBB—lumbar or sacral (third level): 64495.
Note: Codes based upon spinal level/facet joint, not individual medial branches. Each facet joint is innervated by two different medial branch nerves. Hence, an L3-5 medial branch block, deinnervates the L4/5 and L5/S1 facet joint, therefore can only be billed as a first and second level procedure.
Facet Joint Radiofrequency Ablation (Fluoroscopy is not Bundled)
- Medial branch cervical or thoracic (first joint): 64633
- Medial branch cervical or thoracic (each additional joint): 64634
- Medial branch lumbar or sacral (first joint): 64635
- Radiofrequency ablation (RFA)—lumbar or sacral (each additional joint): 64636.
Spinal Cord Stimulator Trial—Cervical or Thoracolumbar (Fluoroscopy is Bundled)
- Percutaneous lead placement: 63650—bill × 2 if trial required 2 leads
- Includes 10-day global period.
Discogram/Discography (Fluoroscopy is Bundled)
- Lumbar discogram/discography (each disk): 62290.
Intrathecal Trial (Fluoroscopy is not Bundled)
- Injection of diagnostic substance (anesthetics, antispasmotics, opioids solutions) into the epidural or subarachnoid space: 62322.
Joints and Bursa—Injection or Aspiration (Fluoroscopy is not Bundled)
- Major joint/bursa: 20610 (knee, hip, shoulder, trochanteric bursa, subacromial bursa, pes anserine bursa)
- Intermediate joint/bursa: 20605 (temporomandibular, acromioclavicular, wrist, elbow, ankle, olecranon bursa)
- Minor joint/bursa: 20600 [fingers proximal interphalangeal (PIP), distal interphalangeal (DIP), toes, carpometacarpal 20604]
- Sacroiliac joint (SIJ) with fluoroscopy: 27096
- Sacral (S1-S3) lateral branch blocks: 64450 × 3
- Use 77003 instead of 77002
- RFA of L5 dorsal primary ramus and S1-S3 lateral branches: 64640 × 4
- Genicular nerve (knee) blocks: 64450 × 3 units
Fluoroscopic Guidance (for Non-bundled Procedures)
- Fluoroscopic guidance for non-spinal procedures: 77002
- Fluoroscopic guidance for spinal procedures: 77003.
- Applies only to an office visit with a procedure: 25
- Bilateral procedures: 50
- Incomplete procedure (patient did not tolerate procedure): 52
- Aborted procedure (patient's well-being at risk, i.e. vasovagal): 53
- Distinct procedural service: 59
- It is used on claims to indicate that two procedures reported during the same encounter are separate and distinct from each other and eligible for separate and unreduced payment.
Target angles have been described in Table 1.1.
- Schueler BA. The AAPM/RSNA physics tutorial for residents: general overview of fluoroscopic imaging. Radiographics. 2000;20(4):1115–26.
- Stocker DM, Bonsu B. A rule based on body weight for predicting the optimum depth of spinal needle insertion for lumbar puncture in children. Acad Emerg Med. 2005;5:105–6.
- http://www.cms.gov/ICD10; accessed September 2017.