dollyleaf5
Contributor
I need some help coding this scenario: The procedure is Rt side sacroiliac joint radiofrequency thermocoagulation pain block. The doctors office is using code 64640 but I am not sure since in the past for RFTC we have used 64622-64627. Please see the report below. Thank you
PROCEDURE PERFORMED: Right side sacroiliac joint, radiofrequency thermocoagulation, S1-S3.
ANESTHESIA: Monitored sedation
PROCEDURE NOTE: After explaining risks, benefits, and complications of procedure, an informed written consent was obtained. The patient was taken to the fluoroscopy suite and placed in a prone position. Full draping was applied. Skin was cleansed with Betadine x3 in proper sterile fashion. Sterile drapes were applied. Using a #25 gauge needle, right sacroiliac joint was seen under fluoroscopy. The medial border of the joint was identified. Skin wheals were made in three different points at the medial border. Three SMK needles inserted into each level. The fourth needle was inserted at the right sacral ala. Testing _____(01:20) needle was done for sensory and motor stimulation. The patient did not have any shooting pain down the right lower extremity. Lesioning was performed till 80 degrees for 90 seconds in each needle. Previous to lesioning, a 0.5 cc of 0.25% ropivacaine was injected in each needle. The needle was withdrawn. The patient tolerated the procedure well and was transferred to recovery room for further vital signs monitoring. I will be refilling the patient medication for the next month. The patient to have the left side done in two weeks.
PROCEDURE PERFORMED: Right side sacroiliac joint, radiofrequency thermocoagulation, S1-S3.
ANESTHESIA: Monitored sedation
PROCEDURE NOTE: After explaining risks, benefits, and complications of procedure, an informed written consent was obtained. The patient was taken to the fluoroscopy suite and placed in a prone position. Full draping was applied. Skin was cleansed with Betadine x3 in proper sterile fashion. Sterile drapes were applied. Using a #25 gauge needle, right sacroiliac joint was seen under fluoroscopy. The medial border of the joint was identified. Skin wheals were made in three different points at the medial border. Three SMK needles inserted into each level. The fourth needle was inserted at the right sacral ala. Testing _____(01:20) needle was done for sensory and motor stimulation. The patient did not have any shooting pain down the right lower extremity. Lesioning was performed till 80 degrees for 90 seconds in each needle. Previous to lesioning, a 0.5 cc of 0.25% ropivacaine was injected in each needle. The needle was withdrawn. The patient tolerated the procedure well and was transferred to recovery room for further vital signs monitoring. I will be refilling the patient medication for the next month. The patient to have the left side done in two weeks.