adeguzman
New
What should be the proper coding for procedure below, any help is greatly appreciated. thank you.
The patient was seen and examined in the preoperative holding area. The risks and benefits of the procedure were discussed with the patient. Informed consent was obtained. The patient's history and physical were reviewed. IV access was established.
The patient was taken to the operating room and positioned prone on the operating room table. The patient was monitored throughout the case with an EKG, pulse oximeter, and blood pressure cuff. The patient was anesthetized with titrated amounts of Versed and fentanyl. The back was sterilely prepped and draped with sterile towels in the usual fashion.
A brief fluoroscopic survey of the patient's back was performed. Under a facet view by correcting the caudocephalad angulation and obliquing the machine approximately 25-30 degrees to the left, the facets were outlined. The area of the radial branch distribution was outlined by outlining the transverse process, superior articular process, and pedicle.
Next, three 410, 10-mm exposed tip RK radiofrequency needles were advanced and placed at the junction of the superior articular process, transverse process, and pedicle on the right. Sensory stimulation was performed at each site at 50 Hz which was positive for reproduction of the patient's pain at 0.5 on a 0 to 1 intensity. Motor stimulation was performed up to 2 Hz which was negative for any motor root stimulation.
Next, approximately 1 mL of 0.25% bupivacaine and about 15 mg of Kenalog was injected through each needle at each site. Each level was then lesioned to a maximum temperature of 90 degrees for 90 seconds. The needles were withdrawn.
The patient tolerated the procedure and anesthesia well and left the operating room in stable condition without any evidence of intravascular or intrathecal or motor or sensory sequelae.
DISPOSITION: The patient was discharged home in stable condition and was asked to take bedrest for the rest of the day. The patient was asked to report any untoward events to my office immediately. Otherwise, the patient will be followed up in a routine fashion in about two weeks' time.
The patient was seen and examined in the preoperative holding area. The risks and benefits of the procedure were discussed with the patient. Informed consent was obtained. The patient's history and physical were reviewed. IV access was established.
The patient was taken to the operating room and positioned prone on the operating room table. The patient was monitored throughout the case with an EKG, pulse oximeter, and blood pressure cuff. The patient was anesthetized with titrated amounts of Versed and fentanyl. The back was sterilely prepped and draped with sterile towels in the usual fashion.
A brief fluoroscopic survey of the patient's back was performed. Under a facet view by correcting the caudocephalad angulation and obliquing the machine approximately 25-30 degrees to the left, the facets were outlined. The area of the radial branch distribution was outlined by outlining the transverse process, superior articular process, and pedicle.
Next, three 410, 10-mm exposed tip RK radiofrequency needles were advanced and placed at the junction of the superior articular process, transverse process, and pedicle on the right. Sensory stimulation was performed at each site at 50 Hz which was positive for reproduction of the patient's pain at 0.5 on a 0 to 1 intensity. Motor stimulation was performed up to 2 Hz which was negative for any motor root stimulation.
Next, approximately 1 mL of 0.25% bupivacaine and about 15 mg of Kenalog was injected through each needle at each site. Each level was then lesioned to a maximum temperature of 90 degrees for 90 seconds. The needles were withdrawn.
The patient tolerated the procedure and anesthesia well and left the operating room in stable condition without any evidence of intravascular or intrathecal or motor or sensory sequelae.
DISPOSITION: The patient was discharged home in stable condition and was asked to take bedrest for the rest of the day. The patient was asked to report any untoward events to my office immediately. Otherwise, the patient will be followed up in a routine fashion in about two weeks' time.