Melissa Harris CPC
Expert
Can someone help me with this procedure note Please?
Median Nerve Block
DATE OF PROCEDURE: October 3, 2014
ANESTHESIA: Local/Conscious sedation
PRE-OPERATIVE DIAGNOSIS: 354.0 Carpal Tunnel Syndrome
POST-OPERATIVE DIAGNOSIS: 354.0 Carpal Tunnel Syndrome
INDICATIONS: Right Wrist pain
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits are discussed including but not limited to infection. Per patient request 2 mg of Versed was given IM by the nurse. The patient is brought into the operating room with appropriate monitors and placed sitting upright in a chair with wrist outstretched, with the ventral surface of the wrist extending upward on the procedure room table. The patient was then asked to make a fist, flex at the wrist and the palmaris longus tendon were palpated and marked just medial to the tendon at the skin crease. The area was then prepped in a sterile fashion. Using one 25 gauge 1 1/2 inch needle where advanced downward towards the carpal tunnel at the marked point until a parathesia or uncomfartableness was felt. At this point after careful aspiration reveals no blood, .5mL of 1% Lidocaine and 9 mg of mg/mL Celestone was injected into the Right carpal tunnel. The needle was removed, pressure was appiled and the wound was dressed. The patient was removed from the procedure room in stable condtion and brought to the recovery area having tolerated the procedure well.
Is this 64450 or 20526?
Thank you
Melissa Harris, CPC
Median Nerve Block
DATE OF PROCEDURE: October 3, 2014
ANESTHESIA: Local/Conscious sedation
PRE-OPERATIVE DIAGNOSIS: 354.0 Carpal Tunnel Syndrome
POST-OPERATIVE DIAGNOSIS: 354.0 Carpal Tunnel Syndrome
INDICATIONS: Right Wrist pain
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits are discussed including but not limited to infection. Per patient request 2 mg of Versed was given IM by the nurse. The patient is brought into the operating room with appropriate monitors and placed sitting upright in a chair with wrist outstretched, with the ventral surface of the wrist extending upward on the procedure room table. The patient was then asked to make a fist, flex at the wrist and the palmaris longus tendon were palpated and marked just medial to the tendon at the skin crease. The area was then prepped in a sterile fashion. Using one 25 gauge 1 1/2 inch needle where advanced downward towards the carpal tunnel at the marked point until a parathesia or uncomfartableness was felt. At this point after careful aspiration reveals no blood, .5mL of 1% Lidocaine and 9 mg of mg/mL Celestone was injected into the Right carpal tunnel. The needle was removed, pressure was appiled and the wound was dressed. The patient was removed from the procedure room in stable condtion and brought to the recovery area having tolerated the procedure well.
Is this 64450 or 20526?
Thank you
Melissa Harris, CPC