ortho1991
Guru
Hi everyone
We have a physician that wants to bill a office visit 99213 with the EMG studies. This is what the office note and EMG study note look like all dictated on the same page. Can Dr. bill both O/V and EMG study?? Any advise will be greatly appreciated.
Electrodiagnostic Studies
Patient:???? Age:?????
Sex:???? Referring Dr.????
Date of Birth: ???? Date of Service:????
History: Patient is here for evaluation of chronic RT leg pain and radiculaopaty. He has had prior lumbar spine surgery L2-5 decompression and new L3-4 HNP along with severe bilateral foraminal stenosis L3-S1. ESI has helped temporarily with recurrent pain.
PMH/FH/SH: Reviewed. ROS: positive neuro/musculoskeletal, neg-vascular
PE: Vascular, Lymphatic: examined-wnl Neuro: examined-4/5motor L3/4
NCS Summary: The NCS and F/H Waves are normal.
EMG Summary: Needle exam showed evidence of denervation and reinnevation in the RT L3/4 nerve root. The rest of the Needle exam was normal.
Conclusion: Abnormal Study: 1. There is EMG/NCS evidence for a RT chronic active L3/4 radiculopathy. 2. There is no evidence for a focal neuropathy or peripheral neuropathy.
Patient will see Dr. ??? for further treatment consideration at the time. The patient has had Interventional pain management/and therapy with persistent symptoms. His clinical exam and MRI findings do correlate with the EMG findings with ongoing denervation present. Surgical considerations are supported by this study. All question were answered and results discussed.
We have a physician that wants to bill a office visit 99213 with the EMG studies. This is what the office note and EMG study note look like all dictated on the same page. Can Dr. bill both O/V and EMG study?? Any advise will be greatly appreciated.
Electrodiagnostic Studies
Patient:???? Age:?????
Sex:???? Referring Dr.????
Date of Birth: ???? Date of Service:????
History: Patient is here for evaluation of chronic RT leg pain and radiculaopaty. He has had prior lumbar spine surgery L2-5 decompression and new L3-4 HNP along with severe bilateral foraminal stenosis L3-S1. ESI has helped temporarily with recurrent pain.
PMH/FH/SH: Reviewed. ROS: positive neuro/musculoskeletal, neg-vascular
PE: Vascular, Lymphatic: examined-wnl Neuro: examined-4/5motor L3/4
NCS Summary: The NCS and F/H Waves are normal.
EMG Summary: Needle exam showed evidence of denervation and reinnevation in the RT L3/4 nerve root. The rest of the Needle exam was normal.
Conclusion: Abnormal Study: 1. There is EMG/NCS evidence for a RT chronic active L3/4 radiculopathy. 2. There is no evidence for a focal neuropathy or peripheral neuropathy.
Patient will see Dr. ??? for further treatment consideration at the time. The patient has had Interventional pain management/and therapy with persistent symptoms. His clinical exam and MRI findings do correlate with the EMG findings with ongoing denervation present. Surgical considerations are supported by this study. All question were answered and results discussed.