ollielooya
True Blue
DX is for 346.10, common migraine. Patient presents for acute care treatment at the specialist's office. My question involves a particular paragraph as follows:
Pt. given IV nubain 15 mg and phenergan 50 in 100 ml saline over 30 minutes starting at 2:15 PM and ending at 2:45 PM. Patient complained of burning in the left upper extremity and into her chest at onset of the infusion. An injection of Ativan 2 mg. in 10cc saline was pushed over 5 minutes mc. She was given 100mL of saline intravenously over 30 minutes and then reported some improvement in headaches. Then she was given intravenous phenobarbital 130mg in 100ml saline over 30 minutes starting at 3:30 PM and ending at 4PM. Patient was monitored for 30 minutes. Headache resolved. My thoughts as to codes are:
96365
96375 (new substance push, not initial?)
??? (see below)
96367
HOWEVER, would it be acceptable to code for the saline itself given intravenously and subsequently OVER 30 minutes for therapeutic purposes? I'm stalled at the last paragraph in the guidelines beneath 96361. Please "nudge" me in the right direction...
Suzanne E. Byrum, CPC
Pt. given IV nubain 15 mg and phenergan 50 in 100 ml saline over 30 minutes starting at 2:15 PM and ending at 2:45 PM. Patient complained of burning in the left upper extremity and into her chest at onset of the infusion. An injection of Ativan 2 mg. in 10cc saline was pushed over 5 minutes mc. She was given 100mL of saline intravenously over 30 minutes and then reported some improvement in headaches. Then she was given intravenous phenobarbital 130mg in 100ml saline over 30 minutes starting at 3:30 PM and ending at 4PM. Patient was monitored for 30 minutes. Headache resolved. My thoughts as to codes are:
96365
96375 (new substance push, not initial?)
??? (see below)
96367
HOWEVER, would it be acceptable to code for the saline itself given intravenously and subsequently OVER 30 minutes for therapeutic purposes? I'm stalled at the last paragraph in the guidelines beneath 96361. Please "nudge" me in the right direction...
Suzanne E. Byrum, CPC