jkottarathil
Contributor
One of my providers reported an E/M service with a trigger point injection. Normally I do not have an issue with coding these, but this one is documented a little differently. Normally our providers inject triamcinolone/Kenalog with this type of injection and this is the first time I'm seeing sodium chloride injected. I have queried the provider to confirm that this documentation is correct, and they confirmed it was. Can anyone please help me with how I should code for this service? More specifically, what J-code should be used? Has anyone ever seen this before?
"Risks and benefits discussed, informed consent obtained from patient/POA.
Area prepped with betadine. A 21 gauge needle used to inject 2 cc of 1% lidocaine without epinephrine (NDC #0409-4276-16 Lot # GX3297, Exp. 1/1/25) and 2 mL 0.9% sodium chloride (NDC# 63323-186-04 Lot # 6029026, Exp. 09/24) into (Left upper trapezius). Patient tolerated procedure well with no immediate complications."
Any help is appreciated! Thank you!!
"Risks and benefits discussed, informed consent obtained from patient/POA.
Area prepped with betadine. A 21 gauge needle used to inject 2 cc of 1% lidocaine without epinephrine (NDC #0409-4276-16 Lot # GX3297, Exp. 1/1/25) and 2 mL 0.9% sodium chloride (NDC# 63323-186-04 Lot # 6029026, Exp. 09/24) into (Left upper trapezius). Patient tolerated procedure well with no immediate complications."
Any help is appreciated! Thank you!!