chriscottd
New
Is there any language around the required elements in a Procedure in Detail note? I have a record I am reviewing that is stated to be an L4-5 B TESI in procedure header; but the procedure in detail note mentions the spinal needle "advanced towards the 6 o'clock position of the pedicle at L4-5 and L5-S1 on the right." Then 0.5 mL of contrast injected "reveled spread along the nerve root." no uptake seen...then injected with lidocaine and betamethasone at each level.