missy874
Guru
Can some review this blurb and let me know what it is lacking for trigger point injection documentation?
"Palpatory examination of the trapezius, temporalis, semispinalis cervicis, and supraspinatus revealed 6 active and 3 latent trigger points. Each point was marked and prepped with alcohol. A 27 gauge needle was then inserted and following negative aspiration, used to inject each point with 1ml of 0.5% Marcaine mixed with 0.5% lidocaine and 100mcg cyanocobalamin. Patient tolerated procedure well."
This charge is being discarded as nonbillable because
He told us which muscles he examined and that trigger points were found and injected, but didn't specify which of the muscles examined had the points/injections.
I would like to discuss with the provider how to improve his documentation, but I need a resource that may further specify what he needs..... I, in my ignorance, thought he had a billable charge.
Thanks so much
"Palpatory examination of the trapezius, temporalis, semispinalis cervicis, and supraspinatus revealed 6 active and 3 latent trigger points. Each point was marked and prepped with alcohol. A 27 gauge needle was then inserted and following negative aspiration, used to inject each point with 1ml of 0.5% Marcaine mixed with 0.5% lidocaine and 100mcg cyanocobalamin. Patient tolerated procedure well."
This charge is being discarded as nonbillable because
He told us which muscles he examined and that trigger points were found and injected, but didn't specify which of the muscles examined had the points/injections.
I would like to discuss with the provider how to improve his documentation, but I need a resource that may further specify what he needs..... I, in my ignorance, thought he had a billable charge.
Thanks so much