Melissa Harris CPC
Expert
I am new to Pain Management and need some help coding the following:
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits are discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient is then brought to the operating room and with appropriate monitors in place the patient is placed prone on the fluoroscopic operating room table. The area of the Left low back is prepped and draped in sterile fashion. Under direct fluoroscopic guidance, the sacroiliac joint is visualized. A skin wheal is raised over the joint using 1 mL of 1% Lidocaine. Another 2 mL's is used to infiltrate subcutaneous tissue at each level. Then one 20 gauge 15 cm RF needle with a 5 mm active tip is advanced through the skin wheal and directed toward the inferior aspect of the posterior SI joint. Once bone is contacted, and after careful aspiration reveals no blood, a mixture of 4 mL 0.25% Marcaine and 1 mL of 40mg/mL Kenalog 5 mL of 1% Lidocaine was injected thru the needle before radiofrequency lesioning was begun at 80 degrees for 60 seconds. This is repeated three more times moving up the joint, lesioning at four levels . Once this was completed, the needle was removed, puncture wound was dressed. The patient tolerated the procedure well. The patient was removed to the recovery area in stable condition.
The doctor wants to bill 64640 (and this has been the rule) but in my research I see that 64999 may be more appropriate. Can someone please clarify for me?
Thank you
Melissa![Confused :confused: :confused:](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
DESCRIPTION OF PROCEDURE: With written informed consent obtained, risk and benefits are discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis. Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse. The patient is then brought to the operating room and with appropriate monitors in place the patient is placed prone on the fluoroscopic operating room table. The area of the Left low back is prepped and draped in sterile fashion. Under direct fluoroscopic guidance, the sacroiliac joint is visualized. A skin wheal is raised over the joint using 1 mL of 1% Lidocaine. Another 2 mL's is used to infiltrate subcutaneous tissue at each level. Then one 20 gauge 15 cm RF needle with a 5 mm active tip is advanced through the skin wheal and directed toward the inferior aspect of the posterior SI joint. Once bone is contacted, and after careful aspiration reveals no blood, a mixture of 4 mL 0.25% Marcaine and 1 mL of 40mg/mL Kenalog 5 mL of 1% Lidocaine was injected thru the needle before radiofrequency lesioning was begun at 80 degrees for 60 seconds. This is repeated three more times moving up the joint, lesioning at four levels . Once this was completed, the needle was removed, puncture wound was dressed. The patient tolerated the procedure well. The patient was removed to the recovery area in stable condition.
The doctor wants to bill 64640 (and this has been the rule) but in my research I see that 64999 may be more appropriate. Can someone please clarify for me?
Thank you
Melissa