kadecker
Contributor
Need help, please, regarding the following procedure note. One person says 64445, One says 27093 and another says 20552. What would be the correct CPT code?
The patient was identified in the holding area and the operative permit was explained and signed. I have discussed with the patient the risks, benefits, side effects and complications of a fluoroscopically guided piriformis injection. I have answered the patient's questions regarding the procedure and have given the patient the opportunity to refuse the procedure. I also have discussed alternative methods of treatment. The patient stated understanding of the procedure and wished to proceed with a fluoroscopically guided left sided piriformis injection. The patient was taken to the fluoroscopic suite and placed in a prone position with the appropriate monitors applied. A nurse was in attendance for the duration of the procedure to carefully monitor the patient. Please refer to the nursing record for vital sign documentation and for any doses of sedatives and medications. I was present and gave the order for any medications given to the patient. The patient was positioned prone and the left buttock area was prepped and draped in the usual sterile fashion. AP fluoroscopy was used to identify the line between the lower border of the sacroiliac joint and the greater trochanter of the femur. Subsequently, the needle was advanced in the AP direction toward the imaginary line formed between the previously mentioned landmarks. The needle was advanced under lateral fluoroscopy and stopped just past the anterior portion of the sacrum. Subsequently, one (1) cc of Omnipaque contrast was injected under AP fluoroscopy revealing an outline of the piriformis muscle. Afterwards, 3 cc of 0.25% Bupivacaine and 40 mg Depo-Medrol were injected.
The patient tolerated the procedures well and there were no complications. The patient was taken to the recovery area. The patient remained in stable condition with no apparent complications. Post procedure instructions were given to the patient and a follow up appointment was confirmed. The patient was also discharged with information on how to reach the clinic or "on call" physician at anytime for questions or complaints.
Thank you.
The patient was identified in the holding area and the operative permit was explained and signed. I have discussed with the patient the risks, benefits, side effects and complications of a fluoroscopically guided piriformis injection. I have answered the patient's questions regarding the procedure and have given the patient the opportunity to refuse the procedure. I also have discussed alternative methods of treatment. The patient stated understanding of the procedure and wished to proceed with a fluoroscopically guided left sided piriformis injection. The patient was taken to the fluoroscopic suite and placed in a prone position with the appropriate monitors applied. A nurse was in attendance for the duration of the procedure to carefully monitor the patient. Please refer to the nursing record for vital sign documentation and for any doses of sedatives and medications. I was present and gave the order for any medications given to the patient. The patient was positioned prone and the left buttock area was prepped and draped in the usual sterile fashion. AP fluoroscopy was used to identify the line between the lower border of the sacroiliac joint and the greater trochanter of the femur. Subsequently, the needle was advanced in the AP direction toward the imaginary line formed between the previously mentioned landmarks. The needle was advanced under lateral fluoroscopy and stopped just past the anterior portion of the sacrum. Subsequently, one (1) cc of Omnipaque contrast was injected under AP fluoroscopy revealing an outline of the piriformis muscle. Afterwards, 3 cc of 0.25% Bupivacaine and 40 mg Depo-Medrol were injected.
The patient tolerated the procedures well and there were no complications. The patient was taken to the recovery area. The patient remained in stable condition with no apparent complications. Post procedure instructions were given to the patient and a follow up appointment was confirmed. The patient was also discharged with information on how to reach the clinic or "on call" physician at anytime for questions or complaints.
Thank you.