The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on ultrasound-guided catheterisation of the epidural space.
The epidural space is surrounding the spinal cord, inside the spinal column. Epidural space catheterisation through the middle or lower back is usually performed as part of anaesthetic techniques, in order to inject analgesic drugs. A needle is inserted into the interspinous ligament and advanced very slowly until there is no longer any resistance to the injection of air or saline, indicating that the tip of the needle is in the epidural space. However, there are at times technical difficulties in achieving this. Ultrasound imaging may be used to help identify the epidural space.
The following codes are applied for ultrasound guided catheterisation of the epidural space, except for catheterisation of the epidural space for pain management during delivery and surgery.
A54.8 Other specified therapeutic spinal puncture
Y53.2 Approach to organ under ultrasonic control
Z06.3 Lumbar spinal cord
Note; If the epidural is performed for pain control in labour then Y81.- Spinal anaesthetic is applied in a secondary position., There is no national standard to record administration of anaesthetic during a procedure, therefore these codes would not be used in this scenario.
The NHS Classifications Service of NHS Connecting for Health is the central definitive source for clinical coding guidance and determines the coding standards associated with the classifications (OPCS-4 and ICD-10) to be used across the NHS. The NHS Classifications Service and NICE work collaboratively to ensure the most appropriate classification codes are provided. www.connectingforhealth.co.uk/clinicalcoding