atheri992
Contributor
I code for the Pain Clinic and there are two docs and I've seen it both ways...do I code as (not including laterality, guidance, and meds):
64493
64494
64450 X3
OR
64493
64450 X4
Procedure Note:
SI joint injection technique (RIGHT L4 medial branch nerve and L5 dorsal ramus and lateral branches of the S1, S2, S3 posterior primary rami nerves). Patient was greeted pre-procedure, questions answered and chart reviewed. Consent obtained, vitals were taken, were stable and were charted by nursing staff and the time out was completed prior to procedure, RN present. Cap and Masks were worn by staff in the room. Standard monitors were applied. The patient was placed prone on the fluoroscopy table. The lumbosacral area was prepped with Chlorhexidine and draped in sterile fashion. Using AP fluoroscopy, the skin overlying the target needle placement sites was anesthetized with 0.5% lidocaine. A 22 gauge 3.5 inch needle was placed at the RIGHT L4 medial branch nerve and sacral ala (L5 Dorsal Ramus) and at the lateral margin of the RIGHT S1, S2 & S3 foramina (sacral lateral branches). Correct needle depth was confirmed with contact of bone and lateral fluoroscopy. Following placement of the needles and negative aspiration, 40 mg Triamcinolone mixed with 4 ml of 0.25% bupivacaine was evenly divided and injected at each level. The needles were removed, skin cleansed and sterile bandages applied. The patient tolerated the procedure well and no complications were encountered. Following the procedure the patient's vital signs were stable. The patient was discharged home in good condition with post-procedural instructions.EBL = 0cc
Thank you for any assistance!
64493
64494
64450 X3
OR
64493
64450 X4
Procedure Note:
SI joint injection technique (RIGHT L4 medial branch nerve and L5 dorsal ramus and lateral branches of the S1, S2, S3 posterior primary rami nerves). Patient was greeted pre-procedure, questions answered and chart reviewed. Consent obtained, vitals were taken, were stable and were charted by nursing staff and the time out was completed prior to procedure, RN present. Cap and Masks were worn by staff in the room. Standard monitors were applied. The patient was placed prone on the fluoroscopy table. The lumbosacral area was prepped with Chlorhexidine and draped in sterile fashion. Using AP fluoroscopy, the skin overlying the target needle placement sites was anesthetized with 0.5% lidocaine. A 22 gauge 3.5 inch needle was placed at the RIGHT L4 medial branch nerve and sacral ala (L5 Dorsal Ramus) and at the lateral margin of the RIGHT S1, S2 & S3 foramina (sacral lateral branches). Correct needle depth was confirmed with contact of bone and lateral fluoroscopy. Following placement of the needles and negative aspiration, 40 mg Triamcinolone mixed with 4 ml of 0.25% bupivacaine was evenly divided and injected at each level. The needles were removed, skin cleansed and sterile bandages applied. The patient tolerated the procedure well and no complications were encountered. Following the procedure the patient's vital signs were stable. The patient was discharged home in good condition with post-procedural instructions.EBL = 0cc
Thank you for any assistance!