Melissa Harris CPC
Expert
I need help coding the following. The patient had two procedures, a rigth tibial nervo block at the popliteal fossa and a right hand injection.
PROCEDURE: Right Tibial Nerve Block at the Popliteal Fossa
ANESTHESIA: Local
PRE & POST OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis Unspec
INDICATIONS: Right Foot pain
DESCRIPTION OF PROCEDURE: DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the procedure room and placed on the procedure table in the prone position. The Right popliteal fossa was identified using a skin marker. a mark was made in the midline 7 cm cephalad to the crease. A skin wheal was raised at this point using 1 cc of Lidocaine. Using a nerve stimulator a 22 gauge stimulator needle was passed throught the skin wheal perpindicular to the skin until ankle dorsiflextion begins. The needle was aspirated prior to injecting the above injectating 2 cc's .25% Marcaine and 1 mg of 40 mg/mL Kenalog. The needle was removed and a Band-Aid was placed on the injection site. The patient tolerated this procedure well. There were no complications.
PROCEDURE: RIGHT HAND DIGIT INJECTION
ANESTHESIA: Local
PRE-OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis
POST-OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis
INDICATIONS: RIGHT HAND PAIN
DESCRIPTION OF PROCEDURE: After written informed consent was obtained from the patient and benefits and risks discussed including but not limited to: Benefits being pain relief. Risks being infection bone nerve damage intravascular injection causing infarct of soft tissue.
The patient is brought to the procedure room and is seated on one of the chairs. His right hand is placed on the procedure room table, and it is prepped with Betadine in sterile fashion. Injection is performed on either side of the each of the digits stumps utilizing a half cc on each side of a mixture of 1 mL of 6mg/mL Celestone and 4 cc of 0.25% Marcaine, and 1 mL 1% Lidocaine. Needle is removed puncture wounds were dressed patient tolerated the procedure well.
Any help is greatly appreciated!
Melissa Harris, CPC![Confused :confused: :confused:](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
PROCEDURE: Right Tibial Nerve Block at the Popliteal Fossa
ANESTHESIA: Local
PRE & POST OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis Unspec
INDICATIONS: Right Foot pain
DESCRIPTION OF PROCEDURE: DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the procedure room and placed on the procedure table in the prone position. The Right popliteal fossa was identified using a skin marker. a mark was made in the midline 7 cm cephalad to the crease. A skin wheal was raised at this point using 1 cc of Lidocaine. Using a nerve stimulator a 22 gauge stimulator needle was passed throught the skin wheal perpindicular to the skin until ankle dorsiflextion begins. The needle was aspirated prior to injecting the above injectating 2 cc's .25% Marcaine and 1 mg of 40 mg/mL Kenalog. The needle was removed and a Band-Aid was placed on the injection site. The patient tolerated this procedure well. There were no complications.
PROCEDURE: RIGHT HAND DIGIT INJECTION
ANESTHESIA: Local
PRE-OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis
POST-OPERATIVE DIAGNOSIS: 729.2 Neuralgia/Neuritis/Radiculitis
INDICATIONS: RIGHT HAND PAIN
DESCRIPTION OF PROCEDURE: After written informed consent was obtained from the patient and benefits and risks discussed including but not limited to: Benefits being pain relief. Risks being infection bone nerve damage intravascular injection causing infarct of soft tissue.
The patient is brought to the procedure room and is seated on one of the chairs. His right hand is placed on the procedure room table, and it is prepped with Betadine in sterile fashion. Injection is performed on either side of the each of the digits stumps utilizing a half cc on each side of a mixture of 1 mL of 6mg/mL Celestone and 4 cc of 0.25% Marcaine, and 1 mL 1% Lidocaine. Needle is removed puncture wounds were dressed patient tolerated the procedure well.
Any help is greatly appreciated!
Melissa Harris, CPC