lcole7465
Expert
Our provider saw a New Patient that was referred for a blood patch. Would an E/M be billable along with the blood patch? Below is a snippet of the office note:
HPI: This is a referral from neuralgia department. The patient was seen by the neuralgia department for a potential multiple sclerosis diagnosis. They ordered a lumbar puncture which was performed it 2 days ago then the patient started to develop post dural puncture headache. The headache is much worse when he stands up and gets better when he lays down. He tried conservative treatment including caffeine and lots of fluids with no relief of headache. Headache is throbbing 7/10 when he stands up. He can not stand up more than few minutes then the pain starts come to his the back of his head and radiate to the front of the head. The patient was referred by Neurology for evaluation for a blood patch.
Plan: The patient has severe intractable positional headache after lumbar puncture. He tried conservative treatment including plenty of fluids and caffeine with minimal improvement in the pain. Patient can not stand more than few minutes due to the headache. I discussed with him in detail the risks and the benefits of epidural blood patch including but not limited to bleeding infection nerve damage or may not help him in the headache. I explained to him about the of voiding of coughing sneezing and constipation after the procedure. Patient agreed with the plan. Because of the severity of the headache we will proceed right away with the epidural blood patch.
HPI: This is a referral from neuralgia department. The patient was seen by the neuralgia department for a potential multiple sclerosis diagnosis. They ordered a lumbar puncture which was performed it 2 days ago then the patient started to develop post dural puncture headache. The headache is much worse when he stands up and gets better when he lays down. He tried conservative treatment including caffeine and lots of fluids with no relief of headache. Headache is throbbing 7/10 when he stands up. He can not stand up more than few minutes then the pain starts come to his the back of his head and radiate to the front of the head. The patient was referred by Neurology for evaluation for a blood patch.
Plan: The patient has severe intractable positional headache after lumbar puncture. He tried conservative treatment including plenty of fluids and caffeine with minimal improvement in the pain. Patient can not stand more than few minutes due to the headache. I discussed with him in detail the risks and the benefits of epidural blood patch including but not limited to bleeding infection nerve damage or may not help him in the headache. I explained to him about the of voiding of coughing sneezing and constipation after the procedure. Patient agreed with the plan. Because of the severity of the headache we will proceed right away with the epidural blood patch.
