ortho1991
Guru
We have a discussion going on in the office re documentation for injections and U/S. Doc wants to bill 20552 with 76882 and 76942 here is the procedure note he will dic.
Biceps Tendon USG Injection
? Using ultrasound the biceps tendon groove at the proximal anterior aspect of the humeral head between the medial and lateral tuberosities was identified. The space below the transverse humeral ligament adjacent to the biceps tendon was then identified as the target using ultrasound
? This site was also identified as the point of maximal tenderness by the patient
? An image of the anatomy was recorded and saved to the patient?s record
? The skin and subcutaneous tissue towards the target was anesthetized with lidocaine using a 25ga needle
? Through the anesthetized tissue a 25 ga needle was advanced to the target using direct ultrasound guidance
? Once positioned properly 1cc of 40mg Depomedrol and 1cc lidocaine was injected after negative aspiration
? An image of the injection site was recorded and saved
? The needle tract was flushed with lidocaine as the spinal needle was removed
? No paresthesias were noted from the awake patient and the patient remained stable throughout the procedure
? The patient was monitored for approximately ? hour before being discharged without weakness noted.
My biggest concern is the documentation for the 76882 is this enought to bill with.
Please any suggestions, or advise as to where we can find information will be appreciated. Thank you
Biceps Tendon USG Injection
? Using ultrasound the biceps tendon groove at the proximal anterior aspect of the humeral head between the medial and lateral tuberosities was identified. The space below the transverse humeral ligament adjacent to the biceps tendon was then identified as the target using ultrasound
? This site was also identified as the point of maximal tenderness by the patient
? An image of the anatomy was recorded and saved to the patient?s record
? The skin and subcutaneous tissue towards the target was anesthetized with lidocaine using a 25ga needle
? Through the anesthetized tissue a 25 ga needle was advanced to the target using direct ultrasound guidance
? Once positioned properly 1cc of 40mg Depomedrol and 1cc lidocaine was injected after negative aspiration
? An image of the injection site was recorded and saved
? The needle tract was flushed with lidocaine as the spinal needle was removed
? No paresthesias were noted from the awake patient and the patient remained stable throughout the procedure
? The patient was monitored for approximately ? hour before being discharged without weakness noted.
My biggest concern is the documentation for the 76882 is this enought to bill with.
Please any suggestions, or advise as to where we can find information will be appreciated. Thank you