NESmith
Expert
Pre-operative Dx: Coccyx pain/Coccygodynia
Operative procedure: Coccyx trigger point injection
Operative report: With the patient having had an IV started and all routine monitoring to include noninvasive blood pressure cuff 3-lead EKG and continuous pulse oximetry the patient was placed in a prone position. Sterile meticulous prep of the scarl region was performed with Betadine x3 and sterilely draped. under fluoroscopic visualization the coccygeal region was identified. A 22-gauge 5 inch spinal needle was inserted into the sacral coccygeal junction. A solution was prepared containing 1 cc betamethasone 7 mg and 6 cc of 0.25% bupivacaine. The solution was then injected incrementally after negative aspiration. the needle was removed and the area was sterilely cleaned. The patient was brought to the recovery area in stable condition. There were no post procedure complications. the patient had an unchanged neurologic exam at time of discharge and was given standard post procedure instructions as per protocol.
The biller for the provider thinks the code should be 20552. i don't feel this is correct. Please give me your input, I am trying to help the biller because her provider is not.
Thank You as always.
Operative procedure: Coccyx trigger point injection
Operative report: With the patient having had an IV started and all routine monitoring to include noninvasive blood pressure cuff 3-lead EKG and continuous pulse oximetry the patient was placed in a prone position. Sterile meticulous prep of the scarl region was performed with Betadine x3 and sterilely draped. under fluoroscopic visualization the coccygeal region was identified. A 22-gauge 5 inch spinal needle was inserted into the sacral coccygeal junction. A solution was prepared containing 1 cc betamethasone 7 mg and 6 cc of 0.25% bupivacaine. The solution was then injected incrementally after negative aspiration. the needle was removed and the area was sterilely cleaned. The patient was brought to the recovery area in stable condition. There were no post procedure complications. the patient had an unchanged neurologic exam at time of discharge and was given standard post procedure instructions as per protocol.
The biller for the provider thinks the code should be 20552. i don't feel this is correct. Please give me your input, I am trying to help the biller because her provider is not.
Thank You as always.