coccyx fracture, coccydynia and injection

[drpainfree]

a patient had a non-displaced transverse coccyx fracture about 4 months ago. treated with nasal calcitonin for 2 months in the beginning of year. pain was improving, then plateaued. For last month or so reporting pain seemed to be regressing, particularly with sitting. My concern is now we're dealing with chronic cocydynia.

would it be too soon to do cortisone injection around area? will you be concerned of cortisone impeding fracture healing 4 months after?

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[SSdoc33]

a patient had a non-displaced transverse coccyx fracture about 4 months ago. treated with nasal calcitonin for 2 months in the beginning of year. pain was improving, then plateaued. For last month or so reporting pain seemed to be regressing, particularly with sitting. My concern is now we're dealing with chronic cocydynia.

would it be too soon to do cortisone injection around area? will you be concerned of cortisone impeding fracture healing 4 months after?

you can do the injection.

ganglion impar

 

[CleanUp]

Ganglion impar then RFA

 

[GoBeers]

Sacrococcygeal nerve block

 

[Orin]

Coccygeoplasty

 

[drpainfree]

you can do the injection.

ganglion impar

are you (and everyone) saying to avoid cortisone injection? Ganglion impar requires cortisone. My question is whether or not cortisone spread to fracture line will impede healing, 4 months after fx.

 

[RoloTomassi]

Should be healed by now

 

[SSdoc33]

are you (and everyone) saying to avoid cortisone injection? Ganglion impar requires cortisone. My question is whether or not cortisone spread to fracture line will impede healing, 4 months after fx.

no, its fine. you can use cortisone.

 

[Doctodd]

If I’m reading your post correctly “For last month or so reporting pain seemed to be regressing”…..why inject anything? Check an X-ray to see if it’s healed and not a non-union. Don’t assume it’s healed.

 

[MitchLevi]

I inject these regularly with great results. I wait 6 weeks from the time of the injury and then inject it. One of the more effective treatments in my arsenal

 

[drpainfree]

If I’m reading your post correctly “For last month or so reporting pain seemed to be regressing”…..why inject anything? Check an X-ray to see if it’s healed and not a non-union. Don’t assume it’s healed.

thank you. I will re-check

 

[SSdoc33]

If I’m reading your post correctly “For last month or so reporting pain seemed to be regressing”…..why inject anything? Check an X-ray to see if it’s healed and not a non-union. Don’t assume it’s healed.

even if it is a non-union, doesnt necessarily change the treatment. these dont do all that well with surgery.

 

[drpainfree]

even if it is a non-union, doesnt necessarily change the treatment. these dont do all that well with surgery.

good point, but might postpone injection if there there's chance of healing.

 

[Doctodd]

even if it is a non-union, doesnt necessarily change the treatment. these dont do all that well with surgery.

Never said surgery, but if there’s a callous I wouldn’t want cortisone around it.

 

[SSdoc33]

Never said surgery, but if there’s a callous I wouldn’t want cortisone around it.

I guess. I see fragments floating in the breeze all the time down there. Not sure what it means.

 

[oreosandsake]

https://digitalcommons.kansascity.edu/cgi/viewcontent.cgi?article=1572&context=studentpub

 

[Ducttape]

nice case report.

that must have taken forever though... did i read this right? 4 sets of bipolar lesioning each side, at 90 seconds a lesion, total 12 min of lesioning?



historically, the pain from coccyx and sacral injury take a while to go away, and up to a year is not unexpected.

 

[oreosandsake]

nice case report.

that must have taken forever though... did i read this right? 4 sets of bipolar lesioning each side, at 90 seconds a lesion, total 12 min of lesioning?



historically, the pain from coccyx and sacral injury take a while to go away, and up to a year is not unexpected.

Yeah takes a long time
Have used this a lot over the years. Outcomes not as good or consistent as cervical or lumbar RF but still pretty decent.

 

[GoBeers]

What code for ganglion impar? And what associated icd?

 

[nvrsumr]

https://digitalcommons.kansascity.edu/cgi/viewcontent.cgi?article=1572&context=studentpub

I have some of these kcu kids rotate with me as well. Cool.

 

[strike5858]

I inject these regularly with great results. I wait 6 weeks from the time of the injury and then inject it. One of the more effective treatments in my arsenal

What type of injection?

 

[MitchLevi]

Sacrococcygeal with simultaneous ganglion impar.

 

[GoBeers]

how are you guys coding ganglion impar? just as a small joint injection ?

 

[Ducttape]

sympathetic block. 64520.

 

[RoloTomassi]

That's the most appropriate way but a lot of times it won't pay so inject both SC and GI, bill for just small joint.

 

[SSdoc33]

i code it as a sympathetic block, but it doesnt get paid. RVU overlords havent caught on yet. yet

 

[MitchLevi]

I code small joint injxn with fluoro guidance. Overflow the joint and add some anteriorly.

 

[Ducttape]

my system gets paid.

might be due to the fact that the clinic is doing a relatively higher volume of them compared to a heavy spine practice or that we get prior auth...

cie la vie.

 

[SSdoc33]

my system gets paid.

might be due to the fact that the clinic is doing a relatively higher volume of them compared to a heavy spine practice or that we get prior auth...

cie la vie.

i highly doubt that all payers are reimbursing the sympathetic code. some are, and i want to catch those that do rather than bill a different CPT depending on insurance carrier

 

[bedrock]

Since sympathetic block isn’t being paid I bill small joint injection, flouro guidance, and “other” nerve block code

Still not great , but 3 codes that pay is better than one that doesn’t.

 

[Ducttape]

again, we get prior auth beforehand, and as far as i am aware, from what they tell me, we are getting reimbursed for all those who we get prior auth.

those we cannot get prior auth arent getting the injections. thats about 10% of the cases.

 

[TIVAndy]

I do 64999 these days. Used to put lumbar sympathetic and was denied few times

 

[BobBarker]

@Ducttape I would assume the ones getting “auth’ed” are actually “no auth required” and some of those pay and some of those don’t. No auth required but not a covered benefit.

 

[Ducttape]

there definitely are a few of them.

but most, i can see an actual auth number.

 

[MitchLevi]

Here's one from this AM. Mountain biking trip in Utah 12 months ago. Failed internal manipulation attempts, as well as every other modality known to man. She is an employee here. Depo 40mg, bupi 0.25% x 2cc. Small joint injxn, fluoro guidance.

 

[Orin]

64999 or small joint is appropriate.

64520 is incorrect per coding guidance from AMA CPT Assistant since 2007 but some insurers seem to let it slide.
ref: American Medical Association. CPT Assistant. Issue: September 2007; Volume 17: Issue 9. Coding Communication:Surgery: Nervous System. 2007.
I think the argument is that it isn't lumbar or thoracic you're injecting.

 

[SSdoc33]

64999 or small joint is appropriate.

64520 is incorrect per coding guidance from AMA CPT Assistant since 2007 but some insurers seem to let it slide.
ref: American Medical Association. CPT Assistant. Issue: September 2007; Volume 17: Issue 9. Coding Communication:Surgery: Nervous System. 2007.
I think the argument is that it isn't lumbar or thoracic you're injecting.

thats is what they said at IPSIS a couple years ago. but i still bill 64520

 

[SSdoc33]

Here's one from this AM. Mountain biking trip in Utah 12 months ago. Failed internal manipulation attempts, as well as every other modality known to man. She is an employee here. Depo 40mg, bupi 0.25% x 2cc. Small joint injxn, fluoro guidance.

View attachment 386753

why not the impar as well as sacrococcygeal joint? just push a bit farther and get both?

also, i have never seen anyone improve with the "internal techniques" unless there is concomitant pelvic floor tension myalgia. that seems to be a better diagnsosis. but pure coccydynia? not really

 

[Scottie_Dog]

why not the impar as well as sacrococcygeal joint? just push a bit farther and get both?

also, i have never seen anyone improve with the "internal techniques" unless there is concomitant pelvic floor tension myalgia. that seems to be a better diagnsosis. but pure coccydynia? not really

What do you mean by internal techniques? I’ve had some success in the past doing a combo sacrococcygeal joint injection with a caudal ESI. Anyone else do caudal injections for tailbone pain or mostly just GI blocks? There is some literature out there that says caudal esi works as well. Curious what you all think

 

[SSdoc33]

What do you mean by internal techniques? I’ve had some success in the past doing a combo sacrococcygeal joint injection with a caudal ESI. Anyone else do caudal injections for tailbone pain or mostly just GI blocks? There is some literature out there that says caudal esi works as well. Curious what you all think

it means what you think it means

 

[MitchLevi]

why not the impar as well as sacrococcygeal joint? just push a bit farther and get both?

also, i have never seen anyone improve with the "internal techniques" unless there is concomitant pelvic floor tension myalgia. that seems to be a better diagnsosis. but pure coccydynia? not really

I usually do both, but I didn’t yesterday.