So how would you code this 2 procedures:
Procedure #1
THORACIC RADIOFREQUENCY ABLATION WITH FLUOROSCOPYTARGET SITES: T1, T2, T3, and T4 Bilateral (to denerve the joints at C7-T1, T1-2, T2-3, and T3-4).
INDICATIONS FOR PROCEDURE: The patient has chronic back pain not relieved by conservative therapy. The thoacic facet joints were identified as a source of this patient's chronic back pain by diagnostic thoracic facet joint blocks which provided immediate, but temporary relief. Percutaneous radiofrequency denervation of the medial brach nerves supplying the painful facet joints is now planned to provide long lasting relief.
PRE-PROCEDURE EVALUATION: Patient states she has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that she has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed.
VITALS: BP: 121/77 HR: 87 Temp: 98.6 O2 Sat: 96
CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 9.
AVERAGE PAIN SCORE: Patient rates their pain on average at a 9.
Anesthesia: An IV catheter was placed and made secure in the right AC. The following medications were given for sedation by intravenous injection: fentanyl 3ml versed 4ml. Sedation administration start time: 12:57 PM. Sedation end time: 01:15 PM.
Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. Potential complications including extremity numbness and weakness, loss of sensation, motor deficits, death, nerve damage, abnormal sensations, neurologic changes, temporary or permanent paralysis, generalized and/or central nervous system infection, bleeding, infection, headache and/or other serious or life threatening compliactions were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent.
The patient was taken to the procedure room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. The skin overlying the area to be treated was prepped with chlorhexadine and draped in a sterile fashion. The levels to be treated were visualized fluoroscopically in the AP and oblique views. A local anesthetic skin wheal was raised with 2% lidocaine using a 25 gauge needle at each of the levels. Under fluoroscopic guidance, a 20 gauge, 5mm active tip radiofrequency ablation needle was advanced to the junction of the transverse process and superior articular process. Proper needle placement was confirmed in the lateral, oblique, and AP views. There were no parasthesias during needle placement. Sensory, motor and multifidus thresholds were normal. Approximately 1ml of 2% lidocaine was injected at each level. One lesion was performed for 90 seconds and 90 degrees Celcius at each level. Approximately 10mg of Triamcinalone was injected at each level and the needles were withdrawn. The patient tolerated the procedure well and was brought to the recovery area in stable condition. The procedure was performed at the following levels T1, T2, T3, and T4 Bilateral.
Radiation exposure time: 60 seconds
Procedure #2
LUMBAR RADIOFREQUENCY ABLATION WITH FLUOROSCOPYTARGET SITES: L3, L4, L5 AND SACRAL ALA (to denerve the joints at L2-3, L3-4, L4-5, L5-SA) Left
INDICATIONS FOR PROCEDURE: The patient has chronic lower back pain not relieved by conservative therapy. The lumbar facet joints were identified as a source of this patient's chronic lower back pain by diagnostic facet joint blocks which provided immediate, but temporary relief. Percutaneous radiofrequency denervation of the medial brach nerves supplying the painful facet joints is now planned to provide long lasting relief.
PRE-PROCEDURE EVALUATION: Patient states he has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that he has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed.
VITALS: BP: 135/72 HR: 51 Temp: 97.4 O2 Sat: 96
CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 8.
AVERAGE PAIN SCORE: Patient rates their pain on average at a 8.
Anesthesia: An IV catheter was placed and made secure in the left AC. The following medications were given for sedation by intravenous injection: fentanyl 1ml versed 2ml. Sedation administration start time: 08:10 AM. Sedation end time: 08:40 AM. An independent trained observer monitored the patient's level of consciousness and physiological status throughout the procedure.
Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. Potential complications including lower extremity numbness and weakness, loss of sensation, motor deficits, death, nerve damage, abnormal sensations, neurologic changes, temporary or permanent paralysis, generalized and/or central nervous system infection, bleeding, infection, headache and/or other serious or life threatening complications were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent.
The patient was taken to the procedure room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. The skin overlying the area to be treated was prepped with chlorhexadine and draped in a sterile fashion. The levels to be injected were visualized fluoroscopically in the AP and oblique positions. A local anesthetic skin wheal was raised with 2% lidocaine using a 25 gauge needle at each of the levels. Under fluoroscopic guidance, a 20 gauge, 10mm active tip radiofrequency ablation needle was advanced to the junction of the transverse process and superior articular process. Proper needle placement was confirmed in the lateral, oblique, and AP views. There were no parasthesias during needle placement. Sensory, motor and multifidus thresholds were normal. Approximately 1ml of 2% lidocaine was injected at each level. Two lesions were performed for 90 seconds and 90 degrees Celcius at each level. Approximately 10mg of Triamcinalone was injected at each level and the needles were withdrawn. The patient tolerated the procedure well and was brought to the recovery area in stable condition. The procedure was performed at the following levels L3, L4, L5 AND SACRAL ALA Left
Radiation exposure time: 26 seconds
The patient was observed in the recovery area for pain relief and side effects. When stable the patient was discharged home with post procedure instructions.
I feel like the joints listed in paranthesis don't match up with the listed "target sites" which according to the body of the note are referring to the medial branches but at the end of the note is says levels. Maybe I am missing something. I have to talk to the Dr, but I want to make sure I know what to clarify with him and how to explain the coding.