CoderinJax
Guru
I'm in need of some assistance to verify that an Op Report was documented correctly for CPT codes 27093 and 73525. Below is how the report reads:
"PROCEDURE NOTE- AP and lateral views of the left hip were performed to identify the left hip joint. There is no evidence of fracture or dislocation. Using a 22-gauge 5" needle, the needle was placed into the LT hip joint using the lateral approach with frequent AP and lateral imaging to ensure accurate placement.
1 ml of Isovue-M 300 was injected slowly under fluoro and once the needle entered the superior aspect of the joint, aspiration was negative for blood/fluid.
ARTHROGRAM- Following the administration of contrast, the joint was visualized. No evidence of fracture or dislocation or abnormality. I injected Ancef 1 gram and remaining volume of .25% preservative free lidocaine was injected into the LT hip."
Does this support both 27093 and 73525? Should there be stored images as well?
Thanks!
"PROCEDURE NOTE- AP and lateral views of the left hip were performed to identify the left hip joint. There is no evidence of fracture or dislocation. Using a 22-gauge 5" needle, the needle was placed into the LT hip joint using the lateral approach with frequent AP and lateral imaging to ensure accurate placement.
1 ml of Isovue-M 300 was injected slowly under fluoro and once the needle entered the superior aspect of the joint, aspiration was negative for blood/fluid.
ARTHROGRAM- Following the administration of contrast, the joint was visualized. No evidence of fracture or dislocation or abnormality. I injected Ancef 1 gram and remaining volume of .25% preservative free lidocaine was injected into the LT hip."
Does this support both 27093 and 73525? Should there be stored images as well?
Thanks!