celcano
Networker
My physician sis an "intrathecal injection of fentanyl for intrathecal pump trial".
His report reads: "The skin and subcutaneous tissues were anesthetized with 1% Lidocaine using a 25-gauge 1-1/2 inch needle. After that, an 22-gauge, 3-1/2 inch spinal needle was advanced into the right L2-L3 interspace. The needle's position was verified in both AP and lateral views. A free flow of clear CSF was obtained. 50 mcg fentanyl was given intrathecally. IV dye contrast was used, it showed great intrathecal placement, no filling defect with contrast or stenosis."
In addition to CPT 62311, he wants to bill myleography (72265). I don't see any CCI edits, but I am wondering if this is appropriate? If it is appropriate, is there enough documentation as this is the only report.
Thank you!
His report reads: "The skin and subcutaneous tissues were anesthetized with 1% Lidocaine using a 25-gauge 1-1/2 inch needle. After that, an 22-gauge, 3-1/2 inch spinal needle was advanced into the right L2-L3 interspace. The needle's position was verified in both AP and lateral views. A free flow of clear CSF was obtained. 50 mcg fentanyl was given intrathecally. IV dye contrast was used, it showed great intrathecal placement, no filling defect with contrast or stenosis."
In addition to CPT 62311, he wants to bill myleography (72265). I don't see any CCI edits, but I am wondering if this is appropriate? If it is appropriate, is there enough documentation as this is the only report.
Thank you!