ojustus
Contributor
My provider has given codes 62311 & 64483 and they are for the same level. This is not billable this way is it?? I don't see where he took a transforaminal approach so wouldn't 62311 be the correct code by itself? I am noticing he is doing this quite often on injections and I am new to this surgery center. Don't feel comfortable billing both of these. Procedure note is below.
Please give me feedback. Thanks!!!!
Olivia
Report Type: Procedure note
Pre op Diagnosis: herniated lumbar disc L5-S1 left, with severe sciatic pain
Post op Diagnosis: herniated lumbar disc L5-S1 left, with severe sciatic pain
Procedure: Lumbar epidural steroid injection, L5-S1 left-sided approach, under guided fluoroscopy.
Surgeon:
Anesthesia: Local subcutaneous infiltration of 2% lidocaine.
Title of procedure: Lumbar epidural steroid injection at the level L5-S1 left, under fluoroscopic control, and guidance. Fluoroscopy time approx.30sec. and 10 spot pictures for guidance of needle tip to location. Use of 80 mg of methylprednisolone, with 2% lidocaine approximately 3 cc volume total.
Indications for procedure: this is a 25-year-old woman, who has been suffering with left sciatic pain intermittently secondary to L5-S1 herniated disc, compressing S1 nerve root. Initially she was treated with medical oral pain management, and steroids. She required one a posterior injection approximately 8 weeks ago. She experienced good relief with it. Recently symptoms have been exacerbated, with a pain level 5/10, on daily basis. She was therefore advised consider, second epidural steroid injection. Informed consent was obtained.
Procedure: After informed consent was obtained patient came to the ambulatory surgical center on N November 13, 2013. Preoperative identification was carried out in the holding area. A nurse examined the patient and medical history and physical examination was checked to be accurate and updated within 30 days off the procedure. Consent was checked followed by initial set of vital signs were stable. Allergy and medication list was checked. Patient was then taken to the procedure room where he was placed prone on fluoroscopy table. Abdominal support foam pad was inserted under umbilical area for removing lordosis and opening of interlaminar distance for better access to epidural space. C-arm fluoroscopy was then brought over the patient's lumbar spine and visualization of lumbar spine was confirmed to be excellent for the procedure. A timeout was then performed.
Patient's lumbar area was then prepped and draped in sterile fashion. A Betadine solution and alcohol was used for preparation and allowed to dry for 3 min. Sterile drape then covered the area and opening in the drape giving access to the prepped skin to perform the procedure. Under fluoroscopic guidance a left paralumbar site was selected and marked, at L5-S1.. The 2% lidocaine was used to infiltrate under the skin, to achieve local anesthesia. Patient was observed for any reaction or ill effects. There were no side effects or ill effects. After good local anesthesia was confirmed, a epidural spinal tuohy needle, size 22-gauge, was used to gain access to the epidural space. Needle was inserted through the skin and, subcutaneous tissue and through the ligamentum flavum into the epidural space at L5-S1 slightly left of the midline. The needle tip position was confirmed by loss of resistance technique, as well as air injection. This allowed to visualize the air density in epidural space under fluoroscopy. No egress of CSF seen thru the needle. Following proper confirmation of the needle tip approximately 2cc of methylprednisolone mixed with 1 cc of lidocaine was injected slowly and gradually into the epidural space. Patient was observed for any reaction or side effects. There were no side effects or ill effects. Patient experienced significant pain relief immediately following injection. After needle was withdrawn, Band-Aid was applied. Patient was given a activity restriction instructions. Patient was taken from the procedure room, back to a post procedural holding area, for observation. Post procedure vital signs were confirmed to be stable and after 15 min of observation ,written and verbal instructions were provided, patient was discharged home in stable condition. Patient was advised to report progress over oncoming days and weeks. Also advised if any concerns develop after going home.
Medications provided at the time of discharge: None.
Please give me feedback. Thanks!!!!
Olivia
Report Type: Procedure note
Pre op Diagnosis: herniated lumbar disc L5-S1 left, with severe sciatic pain
Post op Diagnosis: herniated lumbar disc L5-S1 left, with severe sciatic pain
Procedure: Lumbar epidural steroid injection, L5-S1 left-sided approach, under guided fluoroscopy.
Surgeon:
Anesthesia: Local subcutaneous infiltration of 2% lidocaine.
Title of procedure: Lumbar epidural steroid injection at the level L5-S1 left, under fluoroscopic control, and guidance. Fluoroscopy time approx.30sec. and 10 spot pictures for guidance of needle tip to location. Use of 80 mg of methylprednisolone, with 2% lidocaine approximately 3 cc volume total.
Indications for procedure: this is a 25-year-old woman, who has been suffering with left sciatic pain intermittently secondary to L5-S1 herniated disc, compressing S1 nerve root. Initially she was treated with medical oral pain management, and steroids. She required one a posterior injection approximately 8 weeks ago. She experienced good relief with it. Recently symptoms have been exacerbated, with a pain level 5/10, on daily basis. She was therefore advised consider, second epidural steroid injection. Informed consent was obtained.
Procedure: After informed consent was obtained patient came to the ambulatory surgical center on N November 13, 2013. Preoperative identification was carried out in the holding area. A nurse examined the patient and medical history and physical examination was checked to be accurate and updated within 30 days off the procedure. Consent was checked followed by initial set of vital signs were stable. Allergy and medication list was checked. Patient was then taken to the procedure room where he was placed prone on fluoroscopy table. Abdominal support foam pad was inserted under umbilical area for removing lordosis and opening of interlaminar distance for better access to epidural space. C-arm fluoroscopy was then brought over the patient's lumbar spine and visualization of lumbar spine was confirmed to be excellent for the procedure. A timeout was then performed.
Patient's lumbar area was then prepped and draped in sterile fashion. A Betadine solution and alcohol was used for preparation and allowed to dry for 3 min. Sterile drape then covered the area and opening in the drape giving access to the prepped skin to perform the procedure. Under fluoroscopic guidance a left paralumbar site was selected and marked, at L5-S1.. The 2% lidocaine was used to infiltrate under the skin, to achieve local anesthesia. Patient was observed for any reaction or ill effects. There were no side effects or ill effects. After good local anesthesia was confirmed, a epidural spinal tuohy needle, size 22-gauge, was used to gain access to the epidural space. Needle was inserted through the skin and, subcutaneous tissue and through the ligamentum flavum into the epidural space at L5-S1 slightly left of the midline. The needle tip position was confirmed by loss of resistance technique, as well as air injection. This allowed to visualize the air density in epidural space under fluoroscopy. No egress of CSF seen thru the needle. Following proper confirmation of the needle tip approximately 2cc of methylprednisolone mixed with 1 cc of lidocaine was injected slowly and gradually into the epidural space. Patient was observed for any reaction or side effects. There were no side effects or ill effects. Patient experienced significant pain relief immediately following injection. After needle was withdrawn, Band-Aid was applied. Patient was given a activity restriction instructions. Patient was taken from the procedure room, back to a post procedural holding area, for observation. Post procedure vital signs were confirmed to be stable and after 15 min of observation ,written and verbal instructions were provided, patient was discharged home in stable condition. Patient was advised to report progress over oncoming days and weeks. Also advised if any concerns develop after going home.
Medications provided at the time of discharge: None.
