sarthur
Networker
We are starting a new Botox program in our office and wanted to see if our documentation is covering all our bases before we proceed. The documentation states:
"The patient was brought to the procedure room and placed on the procedure table. The procedure area was aseptically prepped and draped. Botox neck Lt Cervical Risks Benefits were discussed with the patient. Complications including weakness was discussed with the patient. 50 units (1 syringe) was utilized using a 30 gauge needle into the following sites. 25 unites injected into left trapezius, 5 units injected into the left occipitalis, 5 units injected into high left cervical paraspinals, 5 units were injected into low cervical paraspinals, 5 units were injected into the left high SCM and 5 units were injected into the left mid paraspinals. 150 units wasted. The procedure area was aseptically bandaged. The patient was transported to the recovery area in stable condition."
Does anyone with more experience know if the documentation is complete enough to support the 64616 charge or if we need to add anything? I appreciate any help!
"The patient was brought to the procedure room and placed on the procedure table. The procedure area was aseptically prepped and draped. Botox neck Lt Cervical Risks Benefits were discussed with the patient. Complications including weakness was discussed with the patient. 50 units (1 syringe) was utilized using a 30 gauge needle into the following sites. 25 unites injected into left trapezius, 5 units injected into the left occipitalis, 5 units injected into high left cervical paraspinals, 5 units were injected into low cervical paraspinals, 5 units were injected into the left high SCM and 5 units were injected into the left mid paraspinals. 150 units wasted. The procedure area was aseptically bandaged. The patient was transported to the recovery area in stable condition."
Does anyone with more experience know if the documentation is complete enough to support the 64616 charge or if we need to add anything? I appreciate any help!