ejthornton
Contributor
How would you code the following? Any input would be greatful!
Post-op diagnosis: Lumbar Radiculitis
Procedure Performed: Flouroscopic Guidance, Bilateral Transforaminal Epidural Steroid Injection
*
Description of Procedure;
Informed consent was obtained. Standard monitors were applied. The patient was reexamined, turned into the prone position and sterilely prepped and draped. Skin wheals were made with a total of 5 cc 1% lidocaine. Using biplanar fluoroscopic guidance a 22 guage 5 inch quincke block needle was advanced at the 6 O'clock position underneath the pedicles at L4 Bilateral, L5 Bilateral and S1 Bilateral. Once the needle tip was felt to be in the appropriate position, the xray beam was turned to the lateral projection to demonstrate the needle tip over the neuroforamen. After negative aspiration, 0.2 cc's of Isovue-300 contrast media was injected at each level to demonstrate proper epidural/selective nerve root spread without any indication of intravascular or subarachnoid uptake. Subsequently, and again after negative aspiration at each level, 0.5cc of 6 mg Betamethasone and 0.3 cc's of 1% preservative free Lidocaine was injected at each level. No paresthesia was noted with final position and contrast provacation was negative. The patient tolerated the procedure well. A detailed report was given to the receiving nurse.
*
Additional Comments:
Specimens Removed: None
Complications: None
Estimated Blood Loss: None
Findings: The patient was reevaluated immediately post-procedure and then again after 10 minutes.
Fluoro:30 secs
*
PLAN:
The patient is to follow up in the office in 2 weeks.
Post-op diagnosis: Lumbar Radiculitis
Procedure Performed: Flouroscopic Guidance, Bilateral Transforaminal Epidural Steroid Injection
*
Description of Procedure;
Informed consent was obtained. Standard monitors were applied. The patient was reexamined, turned into the prone position and sterilely prepped and draped. Skin wheals were made with a total of 5 cc 1% lidocaine. Using biplanar fluoroscopic guidance a 22 guage 5 inch quincke block needle was advanced at the 6 O'clock position underneath the pedicles at L4 Bilateral, L5 Bilateral and S1 Bilateral. Once the needle tip was felt to be in the appropriate position, the xray beam was turned to the lateral projection to demonstrate the needle tip over the neuroforamen. After negative aspiration, 0.2 cc's of Isovue-300 contrast media was injected at each level to demonstrate proper epidural/selective nerve root spread without any indication of intravascular or subarachnoid uptake. Subsequently, and again after negative aspiration at each level, 0.5cc of 6 mg Betamethasone and 0.3 cc's of 1% preservative free Lidocaine was injected at each level. No paresthesia was noted with final position and contrast provacation was negative. The patient tolerated the procedure well. A detailed report was given to the receiving nurse.
*
Additional Comments:
Specimens Removed: None
Complications: None
Estimated Blood Loss: None
Findings: The patient was reevaluated immediately post-procedure and then again after 10 minutes.
Fluoro:30 secs
*
PLAN:
The patient is to follow up in the office in 2 weeks.