Melissa Harris CPC
Expert
Hello,
We have a new provider that utilizes ultrasound. She performed a limited diagnostic ultrasound on a patient and found tendinopathy, possible tear and bursitis. At the same encounter, she performed a injection of the gluteus medius using ultrasound guidance. My question is, can I code the diagnostic ultrasound and the injection separately? TIA
INDICATIONS: Lateral hip pain, gluteus medius tendinopathy,
PROCEDURE 1: The patient was then brought to the procedure room placed in the Left side-lying position. The Rightgreater trochanter and gluteus medius tendon was identified ultrasound. The right gluteus medius tendon demonstrated mixed echogenicity suggestive of tendinosis. There was tenderness to sonopalpation of the tendon. Hyperechoic signal within the tendon was observed suggestive of calcification. There was anechoic signal within the tendon suggestive of possible tearing. There was additionally anechoic signal suggestive of bursitis.
IMPRESSION: Findings suggestive of right gluteus medius calcific tendinopathy with possible tear and subgluteus medius bursitis.
PROCEDURE 2: With written informed consent obtained, risks and benefits were discussed including but not limited to bleeding, infection, bone damage, joint damage, bruising and hematoma formation. The Ultrasound was used to identify the gluteus medius tendon. The overlying skin was cleansed with alcohol x3. A 25 gauge 2 inch needle was then advanced under continuous ultrasound guidance into the gluteus medius tendon. Once at the target location, a syringe was attached containing a 50:50 mixture of 1% lidocaine and 0.25% bupivacaine for a total of 3cc. This was injected into and overlying the tendon at its insertion. The needle was withdrawn a sterile bandage was placed. The patient tolerated the procedure well. She ambulated out of the clinic following procedure in good condition, noting complete resolution of her pain. There were no complications.
PRE-OPERATIVE PAIN SCORE: 8/10
POST-OPERATIVE PAIN SCORE: 0/10
We have a new provider that utilizes ultrasound. She performed a limited diagnostic ultrasound on a patient and found tendinopathy, possible tear and bursitis. At the same encounter, she performed a injection of the gluteus medius using ultrasound guidance. My question is, can I code the diagnostic ultrasound and the injection separately? TIA
INDICATIONS: Lateral hip pain, gluteus medius tendinopathy,
PROCEDURE 1: The patient was then brought to the procedure room placed in the Left side-lying position. The Rightgreater trochanter and gluteus medius tendon was identified ultrasound. The right gluteus medius tendon demonstrated mixed echogenicity suggestive of tendinosis. There was tenderness to sonopalpation of the tendon. Hyperechoic signal within the tendon was observed suggestive of calcification. There was anechoic signal within the tendon suggestive of possible tearing. There was additionally anechoic signal suggestive of bursitis.
IMPRESSION: Findings suggestive of right gluteus medius calcific tendinopathy with possible tear and subgluteus medius bursitis.
PROCEDURE 2: With written informed consent obtained, risks and benefits were discussed including but not limited to bleeding, infection, bone damage, joint damage, bruising and hematoma formation. The Ultrasound was used to identify the gluteus medius tendon. The overlying skin was cleansed with alcohol x3. A 25 gauge 2 inch needle was then advanced under continuous ultrasound guidance into the gluteus medius tendon. Once at the target location, a syringe was attached containing a 50:50 mixture of 1% lidocaine and 0.25% bupivacaine for a total of 3cc. This was injected into and overlying the tendon at its insertion. The needle was withdrawn a sterile bandage was placed. The patient tolerated the procedure well. She ambulated out of the clinic following procedure in good condition, noting complete resolution of her pain. There were no complications.
PRE-OPERATIVE PAIN SCORE: 8/10
POST-OPERATIVE PAIN SCORE: 0/10