Please assist me with coding this op note. I have never billed for botox migraine injections and I want to be sure I am billing this correctly. Thanks in advance for all of your help.
OPERATIVE REPORT PROCEDURE: Botox Injection (MIGRAINE PROTOCOL)
PRE-OPERATIVE DIAGNOSIS: Migraine (Classic)
POST-OPERATIVE DIAGNOSIS: same as above
ANESTHESIA: General Anesthesia BLOOD LOSS: minimal COMPLICATIONS: none
DESCRIPTION OF PROCEDURE: After a discussion of the risks and benefits, the patient consented to the procedure. The patient was taken to the procedure room and placed initially iin a prone position. The upper back, neck, and occipital area was prepped with Betadine and draped in sterile fashion. The Botox vial containing 100 units, was drawn up in a syringe containing 10cc PF saline.
There are 31 distinct targets in the standard protocol but I am not performing the temporal injections today as all we have is the 100 units. A 30 gauge 1/2 inch needle is used for all of these injections, and a fresh needle is used after every four injections. Again, at each side 5 units Botox A was injected into the SQ tissue at all of the sites except for the temporal ones (bilaterally). After completing all of the posterior injections the patient was turned to a supine position, and the head and neck was prepped.
These sites were injected suing the same technique. The patient tolerated the procedure well and there were no adverse events noted.