dyoungberg
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This procedure was done 10/12/2011. Can anyone tell me what the correct coding would be for this please?
PROCEDURE:
1. RADIOFREQUENCY FOR S1 AND S2 MEDIAL BRANCH ON THE RIGHT SIDE
2. FLUOROSCOPY
PREOP DIAGNOSIS: SACROILIITIS
POSTOP DIAGNOSIS: SAME
ANESTHESIA: MAC AVL minimum
COMPLICATIONS: NONE
PRIOR ANTIBIOTIC: NONE
PROCEDURE IN DETAIL: After obtaining consent, patient was moved to the fluoro suite where the patient was placed on the fluoro table in the prone position. Pressure points were checked and the back area was prepped with iodine and draped in a sterile fashion. By using PA and lateral fluoroscopy, and insuring the needle was not deep in the foramina, the target point of S1 and S2 was identified on the right. Target area was identified and skin was infiltrated with Xylocaine 1% using 25G needle.
From this point we advanced 22G needle 3 ½ inches 10 mm active step from the skin towards the target point. We slide the tip of the needle against the target point. Sensory and motor simulation was done and reproduced the patient's pain to less than 0.5 millivolt. Motor stimulation was negative for any movement in the lower extremities. No muscle contraction was identified with motor stimulation. Heat lesioning was done at this level with 80temperature for 60 seconds. After the lesioning was done, a mixture of 1 cc Decadron (4 mg/ml) and 4 cc normal saline was instilled, and the needle was removed.
The patient tolerated the procedure very well.
The patient was moved to the recovery room where the patient was observed in stable condition before being discharged home. There was no weakness in the lower extremities and the patient moved all extremities freely.
Thanks very much!
PROCEDURE:
1. RADIOFREQUENCY FOR S1 AND S2 MEDIAL BRANCH ON THE RIGHT SIDE
2. FLUOROSCOPY
PREOP DIAGNOSIS: SACROILIITIS
POSTOP DIAGNOSIS: SAME
ANESTHESIA: MAC AVL minimum
COMPLICATIONS: NONE
PRIOR ANTIBIOTIC: NONE
PROCEDURE IN DETAIL: After obtaining consent, patient was moved to the fluoro suite where the patient was placed on the fluoro table in the prone position. Pressure points were checked and the back area was prepped with iodine and draped in a sterile fashion. By using PA and lateral fluoroscopy, and insuring the needle was not deep in the foramina, the target point of S1 and S2 was identified on the right. Target area was identified and skin was infiltrated with Xylocaine 1% using 25G needle.
From this point we advanced 22G needle 3 ½ inches 10 mm active step from the skin towards the target point. We slide the tip of the needle against the target point. Sensory and motor simulation was done and reproduced the patient's pain to less than 0.5 millivolt. Motor stimulation was negative for any movement in the lower extremities. No muscle contraction was identified with motor stimulation. Heat lesioning was done at this level with 80temperature for 60 seconds. After the lesioning was done, a mixture of 1 cc Decadron (4 mg/ml) and 4 cc normal saline was instilled, and the needle was removed.
The patient tolerated the procedure very well.
The patient was moved to the recovery room where the patient was observed in stable condition before being discharged home. There was no weakness in the lower extremities and the patient moved all extremities freely.
Thanks very much!