carrollalicia1
Contributor
Hello,
Please assist me with coding this op note. I have never billed for botox migraine injections and I want to be sure I am billing this correctly. Thanks in advance for all of your help.
OPERATIVE REPORT PROCEDURE: Botox Injection (MIGRAINE PROTOCOL)
PRE-OPERATIVE DIAGNOSIS: Migraine (Classic)
POST-OPERATIVE DIAGNOSIS: same as above
ANESTHESIA: General Anesthesia BLOOD LOSS: minimal COMPLICATIONS: none
DESCRIPTION OF PROCEDURE: After a discussion of the risks and benefits, the patient consented to the procedure. The patient was taken to the procedure room and placed initially iin a prone position. The upper back, neck, and occipital area was prepped with Betadine and draped in sterile fashion. The Botox vial containing 100 units, was drawn up in a syringe containing 10cc PF saline.
There are 31 distinct targets in the standard protocol but I am not performing the temporal injections today as all we have is the 100 units. A 30 gauge 1/2 inch needle is used for all of these injections, and a fresh needle is used after every four injections. Again, at each side 5 units Botox A was injected into the SQ tissue at all of the sites except for the temporal ones (bilaterally). After completing all of the posterior injections the patient was turned to a supine position, and the head and neck was prepped.
These sites were injected suing the same technique. The patient tolerated the procedure well and there were no adverse events noted.
Assessment
Headache 784.0
Thanks again!