jennyaharvey
Contributor
Hi Everybody,
I have a doctor that documents the procedure performed is "Lateral lumbar 2 through 5 medial branch nerve RFA w/fluroscopy." However, documentation in the body of the note does not mention the word "nerve" or medial branch anywhere in the documentation. The documentation is as follows below. My question is: Does the nerve(s) treated with RFA have to be documented within the body of the note, or can they just document the levels/areas treated as seen below.
Documentation sample:
The left L3-L4-L5 transverse process and sacral ala were Identified using fluoroscopy. A lidocaine skin wheal was raised above each of these areas. A total of 4 10 cm radiofrequency probe with 10 mm curved tips were advanced from the left side under fluoroscopic guidance to have the needle tip lie along the cephalad medial border of the transverse process at L3-L4-L5 and at the junction of the sacral ala with the superior articular process of S1 on the left. Her and sensory stimulation was carried out through each needle. 1 cc of 0.25% bupivacaine was injected through each needle. Radiofrequency ablation was carried out at 80 °C for 90 seconds at each of these 4 levels. Those were removed. The right transverse process at L3-L4-l5 and the sacral ala was Identified using fluoroscopy. A lidocalne skin wheal was raised above each of these areas. A 10 cm cooled radlofrequency probe with a 4 mm tip was advanced at each of these 4 levels under fluoroscopic guidance to have the needle tip contact the cephalad medial border of the transverse process at L3-L4 and LS and the contact the junction of the sacral ala with the superior articular process of S1 on the right. Motor stimulation was carried out through each of these 4 needles. 1 cc of 0.25% bupivacaine was injected through each of the 4 needles. Cooled Radlofrequency ablation was carried out at 60 °C for 150 seconds at each of these 4 levels. Needles were removed. Patient was taken to recovery room in stable condition.
I have a doctor that documents the procedure performed is "Lateral lumbar 2 through 5 medial branch nerve RFA w/fluroscopy." However, documentation in the body of the note does not mention the word "nerve" or medial branch anywhere in the documentation. The documentation is as follows below. My question is: Does the nerve(s) treated with RFA have to be documented within the body of the note, or can they just document the levels/areas treated as seen below.
Documentation sample:
The left L3-L4-L5 transverse process and sacral ala were Identified using fluoroscopy. A lidocaine skin wheal was raised above each of these areas. A total of 4 10 cm radiofrequency probe with 10 mm curved tips were advanced from the left side under fluoroscopic guidance to have the needle tip lie along the cephalad medial border of the transverse process at L3-L4-L5 and at the junction of the sacral ala with the superior articular process of S1 on the left. Her and sensory stimulation was carried out through each needle. 1 cc of 0.25% bupivacaine was injected through each needle. Radiofrequency ablation was carried out at 80 °C for 90 seconds at each of these 4 levels. Those were removed. The right transverse process at L3-L4-l5 and the sacral ala was Identified using fluoroscopy. A lidocalne skin wheal was raised above each of these areas. A 10 cm cooled radlofrequency probe with a 4 mm tip was advanced at each of these 4 levels under fluoroscopic guidance to have the needle tip contact the cephalad medial border of the transverse process at L3-L4 and LS and the contact the junction of the sacral ala with the superior articular process of S1 on the right. Motor stimulation was carried out through each of these 4 needles. 1 cc of 0.25% bupivacaine was injected through each of the 4 needles. Cooled Radlofrequency ablation was carried out at 60 °C for 150 seconds at each of these 4 levels. Needles were removed. Patient was taken to recovery room in stable condition.
