Melissa Harris CPC
Expert
Hello,
Can someone review the below procedure note and tell me if this is a coccyx injection (and what is the appropriate code) or a coccyx nerve block?? I believe it is only the injection. The office I work at has been coding a nerve block.
PROCEDURE: COCCYX INJECTION
DIAGNOSIS: 722.52 - Intervertebral Disc Degeneration Lumbar, 724.2 - Lumbago, 729.2 - Neuralgia Neuritis & Radiculitis Unspec
INDICATIONS: BACK AND LEG PAIN
ANESTHESIA: Local
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits were discussed including but not limited to infection, bleeding, swelling, bone, nerve and joint damage. The patient was then brought into the operating room with appropriate monitors in place, the patient was placed on the procedure room table in the prone position. Utilizing fluoroscopic guidance, the sacrococcygeal junction was brought into fluoroscopic Anterior Posterior view, a lateral view of the coccyx was then attained. The area was then prepped and drapped in a sterile fashion. A small skin wheel was raised directly over the sacrococcygeal junction using 1mL of 1% Lidocaine. A 22 gauge 3.5 inch spinal needle was then advanced downward to the sacrococcygeal junction and entered at the first interspace. At this point after careful aspiration reveals no blood, needle placement is confirmed using 1 ml of 300mg/ml of Omnipaque before a 1 mL mixture of 2 mL .25% Marcaine, 2 mL 1% Lidocaine, and 1 ml of 40 mg/mL Kenalog was injected. The needle was then walked downward to the mid-coccyx region where another 1 mL of the above mixture was injected. The needle was again walked downward to the distal coccyx where the remaining injectate was injected after aspiration revealed no blood. The needle was then removed, puncture wound was dressed. The patient was removed from the procedure room table in stable condition and brought to the recovery area having tolerated the procedure well.
I greatly appreciate your input!
Melissa Harris, CPC
Can someone review the below procedure note and tell me if this is a coccyx injection (and what is the appropriate code) or a coccyx nerve block?? I believe it is only the injection. The office I work at has been coding a nerve block.
PROCEDURE: COCCYX INJECTION
DIAGNOSIS: 722.52 - Intervertebral Disc Degeneration Lumbar, 724.2 - Lumbago, 729.2 - Neuralgia Neuritis & Radiculitis Unspec
INDICATIONS: BACK AND LEG PAIN
ANESTHESIA: Local
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits were discussed including but not limited to infection, bleeding, swelling, bone, nerve and joint damage. The patient was then brought into the operating room with appropriate monitors in place, the patient was placed on the procedure room table in the prone position. Utilizing fluoroscopic guidance, the sacrococcygeal junction was brought into fluoroscopic Anterior Posterior view, a lateral view of the coccyx was then attained. The area was then prepped and drapped in a sterile fashion. A small skin wheel was raised directly over the sacrococcygeal junction using 1mL of 1% Lidocaine. A 22 gauge 3.5 inch spinal needle was then advanced downward to the sacrococcygeal junction and entered at the first interspace. At this point after careful aspiration reveals no blood, needle placement is confirmed using 1 ml of 300mg/ml of Omnipaque before a 1 mL mixture of 2 mL .25% Marcaine, 2 mL 1% Lidocaine, and 1 ml of 40 mg/mL Kenalog was injected. The needle was then walked downward to the mid-coccyx region where another 1 mL of the above mixture was injected. The needle was again walked downward to the distal coccyx where the remaining injectate was injected after aspiration revealed no blood. The needle was then removed, puncture wound was dressed. The patient was removed from the procedure room table in stable condition and brought to the recovery area having tolerated the procedure well.
I greatly appreciate your input!
Melissa Harris, CPC