Help with hand injection

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Location
Albany
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Can someone tell me what should be billed for this report??

REOPERATIVE DIAGNOSIS: M25.532/31

INDICATIONS: Right hand pain

DESCRIPTION OF PROCEDURE: After written informed consent was obtained, benefits and risks discussed including but not limited to, bleeding, infection, bone damage, joint damage, bruising, and hematoma formation.

The patient is brought to the procedure room and is seated on one of the chairs. The patient's hand is placed on the procedure room table, and it is prepped with Betadine in sterile fashion. Medication was drawn up as 1.5mL of 0.50% Marcaine and 1.5mL of 40mg/mL of Kenolog. Just below the skin toward the nerve using a 3 mL syringe and a 25-gauge 1-1/2 inch needle an injection is performed on either side of the each of the digits. The medication is divided equally between all spots indicated. The needle was removed and the puncture wounds were dressed. The patient tolerated the procedure well.

Injection locations:
1st cmc
2nd mcp
3rd mcp
4th mcp
3 trigger finger injections at base



Fluoroscopic Time: 0-1 Minute
PRE-OPERATIVE PAIN SCORE: 7/10
POST-OPERATIVE PAIN SCORE: 7/10


Thank you :)

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management
 
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