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I am having a hard time understanding when to properly code for Hypertension. I can see coding Hypertension if it was part of the treatment, but in my case it is part of the Past Medical History. Can someone take a look at this Op Note and tell me what they would do in this case? So I can have some better clerification on the matter.
PATIENT:
DOB:
SURGEON:
ADMISSION DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.
POSTOPERATIVE DISCHARGE DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.
PROCEDURE:
Left C5 selective nerve root injection with fluoroscopy.
HISTORY:
Patient presents with the complaint of neck pain with radiation to the left shoulder. He has had prior surgery and prior blocks. He is currently under the expert care of Dr. Lovell who consults for today's injection.
He is advised of the potential benefits, risks, and alternatives as well as complications possible. These can include but are not limited to death, paralysis, spinal cord injury, nerve damage, bleeding, infection, allergic reactions to medications, headache, or loss of control of bladder, bowel, or sexual function. He does wish to proceed.
REVIEW OF SYSTEMS:
Positive for the above.
ALLERGIES:
Dilaudid.
MEDICATIONS:
Exforge, cabergoline, Synthroid, Plaquenil, vitamins, and fish oil.
PAST MEDICAL HISTORY:
Hypertension, hypothyroidism, and pituitary adenoma.
PAST SURGICAL HISTORY:
Lumbar discectomy on two occasions, pituitary adenoma excision, anterior cervical discectomy and fusion, thyroidectomy, and prior blocks.
PATIENT:
FAMILY HISTORY:
Noncontributory.
SOCIAL HISTORY:
Negative for alcohol or tobacco use.
PHYSICAL EXAM:
Reveals a pleasant, 59-year-old, white male, well developed, well nourished, and in some discomfort but in no acute distress. Alert and oriented times three. Height is 6', weight 235, temperature 97.5, blood pressure 169/111, pulse 70, and respirations 16. Head: Nontender. No palpable masses. Cranial nerves grossly intact. Neck: Reduced range of motion with pain that radiates to the left shoulder. Lungs: Clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Bowel sounds are present. Genitourinary is deferred. Extremities: Neck pain with radiation to the left. Strength is symmetric. Deep tendon reflexes are trace. Pulses are intact. Sensation is grossly intact to soft touch.
PROCEDURE:
The patient is taken to the block room, given IV sedation, and monitored. Sterile prep and drape is applied. Local is with 3 cc of 1% plain lidocaine. Using fluoroscopic guidance, a 25-gauge needle is advanced to the neural foramen on the left at the C4-C5 level. This neural foramen was quite narrow, however, the needle was positioned without eliciting a paresthesia and confirmed with three views of image and the injection of contrast. Negative aspiration is then followed with the injection of a test dose lidocaine. This resulted in reduction of pain from a 7 to a 4. There is no evidence of intrathecal block or intravascular injection. The needle was then again negatively aspirated for cerebrospinal fluid or blood and injected with 4 mg of Decadron and 0.5 cc of 1% plain ropivacaine.
The needle is removed intact. There is no blood loss. There are no apparent complications. The patient is without complaints. He is taken to Recovery in good condition. He is asked to maintain a pain log. He will follow with me in four weeks or as needed. He will follow with Dr. Lovell as scheduled.
I AUTHORIZE MY NAME TO BE ELECTRONICALLY AFFIXED TO THIS REPORT SIGNIFYING THAT I HAVE REVIEWED AND APPROVED THE DICTATED REPORT.
PATIENT:
DOB:
SURGEON:
ADMISSION DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.
POSTOPERATIVE DISCHARGE DIAGNOSES:
Cervical spondylosis, cervical radicular pain, neck pain, upper extremity pain, and myofascial pain and spasm.
PROCEDURE:
Left C5 selective nerve root injection with fluoroscopy.
HISTORY:
Patient presents with the complaint of neck pain with radiation to the left shoulder. He has had prior surgery and prior blocks. He is currently under the expert care of Dr. Lovell who consults for today's injection.
He is advised of the potential benefits, risks, and alternatives as well as complications possible. These can include but are not limited to death, paralysis, spinal cord injury, nerve damage, bleeding, infection, allergic reactions to medications, headache, or loss of control of bladder, bowel, or sexual function. He does wish to proceed.
REVIEW OF SYSTEMS:
Positive for the above.
ALLERGIES:
Dilaudid.
MEDICATIONS:
Exforge, cabergoline, Synthroid, Plaquenil, vitamins, and fish oil.
PAST MEDICAL HISTORY:
Hypertension, hypothyroidism, and pituitary adenoma.
PAST SURGICAL HISTORY:
Lumbar discectomy on two occasions, pituitary adenoma excision, anterior cervical discectomy and fusion, thyroidectomy, and prior blocks.
PATIENT:
FAMILY HISTORY:
Noncontributory.
SOCIAL HISTORY:
Negative for alcohol or tobacco use.
PHYSICAL EXAM:
Reveals a pleasant, 59-year-old, white male, well developed, well nourished, and in some discomfort but in no acute distress. Alert and oriented times three. Height is 6', weight 235, temperature 97.5, blood pressure 169/111, pulse 70, and respirations 16. Head: Nontender. No palpable masses. Cranial nerves grossly intact. Neck: Reduced range of motion with pain that radiates to the left shoulder. Lungs: Clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Bowel sounds are present. Genitourinary is deferred. Extremities: Neck pain with radiation to the left. Strength is symmetric. Deep tendon reflexes are trace. Pulses are intact. Sensation is grossly intact to soft touch.
PROCEDURE:
The patient is taken to the block room, given IV sedation, and monitored. Sterile prep and drape is applied. Local is with 3 cc of 1% plain lidocaine. Using fluoroscopic guidance, a 25-gauge needle is advanced to the neural foramen on the left at the C4-C5 level. This neural foramen was quite narrow, however, the needle was positioned without eliciting a paresthesia and confirmed with three views of image and the injection of contrast. Negative aspiration is then followed with the injection of a test dose lidocaine. This resulted in reduction of pain from a 7 to a 4. There is no evidence of intrathecal block or intravascular injection. The needle was then again negatively aspirated for cerebrospinal fluid or blood and injected with 4 mg of Decadron and 0.5 cc of 1% plain ropivacaine.
The needle is removed intact. There is no blood loss. There are no apparent complications. The patient is without complaints. He is taken to Recovery in good condition. He is asked to maintain a pain log. He will follow with me in four weeks or as needed. He will follow with Dr. Lovell as scheduled.
I AUTHORIZE MY NAME TO BE ELECTRONICALLY AFFIXED TO THIS REPORT SIGNIFYING THAT I HAVE REVIEWED AND APPROVED THE DICTATED REPORT.