Thooks0627
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Can somone help me code this please:
Dr. Notes:
Patient came in for occipital nerve block for occipital and trigeminal nerve block and trigger point injections, indicated for intractable and recurring migraine headaches, associated with trigeminal and occipital neuralgia, also cervicalgia with trigger points and muscle spasm. The patient reports her previous set of treatments in December 2012 was very helpful, but symptoms are starting to recur. The patient was evaluated and was found to have tenderness to light pressure over the bilateral supraorbital, anterior auricular, and occipital nerve insertion points, with pressure eliciting dysesthesias along each ipsilateral nerve territory; the patient also had eight identified trigger points, at the bilateral upper cervical paraspinals (C2-C3); the bilateral mid cervical paraspinals (C4-C5); and the bilateral lower cervical paraspinals (C6-C7); and the medial trapezius ridge.
The risks and potential benefits of nerve block and trigger point injections were discussed with the patient, who voiced understanding and gave verbal consent. A total of 1 cc of Kenalog (40 mg) and 5 cc of 0.5% bupivacaine solution were combined. Using a sterile 30-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral supraorbital nerve insertion points and the bilateral auricular nerve insertion points.
Using a sterile 27-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral occipital nerve insertion points, and the remainder was delivered in equal proportions to each of the trigger points listed above.
There was no blood loss, there were no complications, and the patient tolerated the procedure well.
Thanks
Tanya
Dr. Notes:
Patient came in for occipital nerve block for occipital and trigeminal nerve block and trigger point injections, indicated for intractable and recurring migraine headaches, associated with trigeminal and occipital neuralgia, also cervicalgia with trigger points and muscle spasm. The patient reports her previous set of treatments in December 2012 was very helpful, but symptoms are starting to recur. The patient was evaluated and was found to have tenderness to light pressure over the bilateral supraorbital, anterior auricular, and occipital nerve insertion points, with pressure eliciting dysesthesias along each ipsilateral nerve territory; the patient also had eight identified trigger points, at the bilateral upper cervical paraspinals (C2-C3); the bilateral mid cervical paraspinals (C4-C5); and the bilateral lower cervical paraspinals (C6-C7); and the medial trapezius ridge.
The risks and potential benefits of nerve block and trigger point injections were discussed with the patient, who voiced understanding and gave verbal consent. A total of 1 cc of Kenalog (40 mg) and 5 cc of 0.5% bupivacaine solution were combined. Using a sterile 30-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral supraorbital nerve insertion points and the bilateral auricular nerve insertion points.
Using a sterile 27-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral occipital nerve insertion points, and the remainder was delivered in equal proportions to each of the trigger points listed above.
There was no blood loss, there were no complications, and the patient tolerated the procedure well.
Thanks
Tanya