ortho1991
Guru
Hi All,
I need help with this op note.
The patient was taken to the operating room and placed in the prone position. She was
prepped and draped in sterile fashion. Using fluoroscopic guidance, in the AP view, I visualized
the left sacroiliac joint. The target sites for ablation were the bilateral L5 dorsal ramus and
lateral branches of the bilateral S1, S2, and S3. I started first with the left S3 lateral branch.
The target site was the inferolateral border of the foramen. Intermittent fluoroscopic guidance
was used to get to the target site. Prior to insertion of the needle, subcutaneous 1% lidocaine
was injected. At this site, sensory and motor testing were completed. There were no
paresthesias or pain into the patient's lower extremities. Prior to radiofrequency, 0.5 mL of
2% lidocaine was injected through the SMK-type needle. The needle gauge was an 18-gauge
and length was 3-1/2 inches. The site was lesioned at 80 degrees for 90 seconds. The needle
was withdrawn. I carried out the same procedure for the remaining sites as mentioned above.
The patient tolerated the procedure well.
The patient was taken to the recovery room and monitored. She was sent home with discharge
instructions.
I looked at 64640 but really not sure.
I am new to pain mang. and any help or suggestions with this code will be appreicated
Thank you
I need help with this op note.
The patient was taken to the operating room and placed in the prone position. She was
prepped and draped in sterile fashion. Using fluoroscopic guidance, in the AP view, I visualized
the left sacroiliac joint. The target sites for ablation were the bilateral L5 dorsal ramus and
lateral branches of the bilateral S1, S2, and S3. I started first with the left S3 lateral branch.
The target site was the inferolateral border of the foramen. Intermittent fluoroscopic guidance
was used to get to the target site. Prior to insertion of the needle, subcutaneous 1% lidocaine
was injected. At this site, sensory and motor testing were completed. There were no
paresthesias or pain into the patient's lower extremities. Prior to radiofrequency, 0.5 mL of
2% lidocaine was injected through the SMK-type needle. The needle gauge was an 18-gauge
and length was 3-1/2 inches. The site was lesioned at 80 degrees for 90 seconds. The needle
was withdrawn. I carried out the same procedure for the remaining sites as mentioned above.
The patient tolerated the procedure well.
The patient was taken to the recovery room and monitored. She was sent home with discharge
instructions.
I looked at 64640 but really not sure.
I am new to pain mang. and any help or suggestions with this code will be appreicated
Thank you