BrettAAPC
Networker
Hi, I was hoping someone wouldn't mind reading through this doctor's procedure notes to help me figure out all the proper codes to bill out. I am very new to pain management and would be very appreciative if someone could give me some assistance.
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PROCEDURE TYPE: Radiofrequency ablation right L3, L4, L5 and S1 medial branches with the use of fluoroscopy.
INDICATION FOR PROCEDURE: Right-sided low back pain, spondylosis without myelopathy. The patient has 90% pain reduction from diagnostic injections 12/5/12 and he is still feeling better. He desires to undergo radiofrequency ablation as he is leaving for Florida for the winter. Risks and benefits were discussed including infection, bleeding, nerve injury, paralysis, headache, reaction to medication, failure to relieve pain and other potentially serious complications. He understands and wishes to proceed. We discussed he may experience 2-3 weeks of post procedure discomfort requiring continued use of pain medications.
DESCRIPTION OF PROCEDURE: The patient received an I.V. in the holding area. He ambulated to the procedure suite and placed himself prone on the procedure table. Timeout procedure verified correct patient and site. Standard ASA monitors were applied. He was sedated with Versed 2 mg and Fentanyl 50 mcg 7:57-8:33 with the assistance of _____ Skin was numbed with 9 mL of 1% Lidocaine. Using oblique fluoroscopy, 20 gauge Kimberly-Clark Radiofrequency Ablation probes, 10 cm in length with 10 mm active tip were advanced to right L4 and L5 levels for the L3 and L4 median branches. A needle was advanced to Barton's point at the transitional S1-2 level through the L5 dorsal ramus and to the sacral ala for the S1 lateral branch. Needle positions were confirmed under oblique, AP and lateral view of the spine. Aspiration was negative for blood or fluid at each level.
Impedance was 156 ohms at L3, 162 ohms at L4, 192 ohms at L5 and 190 ohms at S1. Sensory was positive at 1 volt at L3, 1 volt at L4, 0.45 volts at L5 and 1.15 volts at S1. Motor testing was negative for lower extremity stimulation at all four levels at 3 volts. I did have positive weak multifidus at L3 and positive multifidus at L4, L5 and S1. Each site was numbed with 1 mL of 2% Lidocaine. Primary lesions were conducted at 80 degrees for 90 seconds. The needles were then rotated and secondary lesions were conducted at 80 degrees for 90 seconds. The needle was slightly repositioned at S1. Motor was retested and this was negative for lower extremity simulation at 3 volts and positive for multifidus.
Needles were rotated at the other sites a third time. Tertiary lesions were conducted at 80 degrees for 90 seconds. The patient was awake and communicative during the lesionins. There were no observed concerns. Total fluoroscopic time was 28 seconds. Each level was injected with one fourth of a mixture of 60 mg of Depo-Medrol and 3.5 mL of 0.5% Bupivacaine. There were no observed complications. The patient was escorted to the Recovery Suite via wheelchair, where he was observed and discharged in stable condition.
Post procedure examination: Alert and oriented x3. The patient is in no acute distress. Vital signs are stable. Motor strength is 5/5 in the bilateral lower extremities. DTRs are 2/4 in the knee and ankles. There are no sensory deficits of the lower extremities. Lumbar spine is minimally tender to palpation.
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Based on this, I would assume all that needs to be coded is 64635, 64636 x 3, 77003-26, and 99144.
Any help would be appreciated. Thanks!
______
PROCEDURE TYPE: Radiofrequency ablation right L3, L4, L5 and S1 medial branches with the use of fluoroscopy.
INDICATION FOR PROCEDURE: Right-sided low back pain, spondylosis without myelopathy. The patient has 90% pain reduction from diagnostic injections 12/5/12 and he is still feeling better. He desires to undergo radiofrequency ablation as he is leaving for Florida for the winter. Risks and benefits were discussed including infection, bleeding, nerve injury, paralysis, headache, reaction to medication, failure to relieve pain and other potentially serious complications. He understands and wishes to proceed. We discussed he may experience 2-3 weeks of post procedure discomfort requiring continued use of pain medications.
DESCRIPTION OF PROCEDURE: The patient received an I.V. in the holding area. He ambulated to the procedure suite and placed himself prone on the procedure table. Timeout procedure verified correct patient and site. Standard ASA monitors were applied. He was sedated with Versed 2 mg and Fentanyl 50 mcg 7:57-8:33 with the assistance of _____ Skin was numbed with 9 mL of 1% Lidocaine. Using oblique fluoroscopy, 20 gauge Kimberly-Clark Radiofrequency Ablation probes, 10 cm in length with 10 mm active tip were advanced to right L4 and L5 levels for the L3 and L4 median branches. A needle was advanced to Barton's point at the transitional S1-2 level through the L5 dorsal ramus and to the sacral ala for the S1 lateral branch. Needle positions were confirmed under oblique, AP and lateral view of the spine. Aspiration was negative for blood or fluid at each level.
Impedance was 156 ohms at L3, 162 ohms at L4, 192 ohms at L5 and 190 ohms at S1. Sensory was positive at 1 volt at L3, 1 volt at L4, 0.45 volts at L5 and 1.15 volts at S1. Motor testing was negative for lower extremity stimulation at all four levels at 3 volts. I did have positive weak multifidus at L3 and positive multifidus at L4, L5 and S1. Each site was numbed with 1 mL of 2% Lidocaine. Primary lesions were conducted at 80 degrees for 90 seconds. The needles were then rotated and secondary lesions were conducted at 80 degrees for 90 seconds. The needle was slightly repositioned at S1. Motor was retested and this was negative for lower extremity simulation at 3 volts and positive for multifidus.
Needles were rotated at the other sites a third time. Tertiary lesions were conducted at 80 degrees for 90 seconds. The patient was awake and communicative during the lesionins. There were no observed concerns. Total fluoroscopic time was 28 seconds. Each level was injected with one fourth of a mixture of 60 mg of Depo-Medrol and 3.5 mL of 0.5% Bupivacaine. There were no observed complications. The patient was escorted to the Recovery Suite via wheelchair, where he was observed and discharged in stable condition.
Post procedure examination: Alert and oriented x3. The patient is in no acute distress. Vital signs are stable. Motor strength is 5/5 in the bilateral lower extremities. DTRs are 2/4 in the knee and ankles. There are no sensory deficits of the lower extremities. Lumbar spine is minimally tender to palpation.
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Based on this, I would assume all that needs to be coded is 64635, 64636 x 3, 77003-26, and 99144.
Any help would be appreciated. Thanks!