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Guys,
For report below,...haven't coded these hardly....can you give me some input...
For 62311, how many times?..and 77003..although perm.images are not documented?
For the ankle...is it 27648/73615 for injxn.for arthrogram. What about the therapeutic injection into ankle...bundled into 27648?
PROCEDURE: Bilateral L5 medial branch blocks with steroid,
right ankle arthrogram, right ankle anesthetic/steroid injection
HISTORY: 17 year old boy with bilateral Bertolotti lesions and
lower back pain, postoperative right clubfoot with ankle pain.
CONSENT: The risks and benefits, including but not limited to
peristent pain, bleeding and infection were explained to the
patient's mother who gave verbal and written consent. Right ankle
was marked.
PROCEDURE TIME: 45 minutes
MEDICATIONS:
Weight 75kgs
Contrast: 8 ml Omnipaque 300
Kenalog 40 mg over L5 posterior elements
Bupivacaine 25 mg over L5 posterior elements
Aristospan 10 mg in right ankle joint
Ropivacaine 3 mg in right ankle joint
PROCEDURE: The boy was placed prone. The skin of the lower back
region was prepped and draped in sterile fashion . Using
fluoroscopic guidance 4 22 gauge needles were inserted from
dorsal approach over each L5 lamina and each L5-S1 lateral
pseudarthrosis. Once position of the needles was confirmed,
Kenalog 40 mg and Bupivacaine 25 mg with contrast was divided in
four doses were injected . The needles were then removed. The
site was dressed with a Dermabond and tegaderm .
The boy was placed supine.
Right ankle joint anterior aspect was prepped. 22 g needle was
inserted anteromedially. 4 ml of contrast was injected for
arthrography. Flat superior talar surface is seen. While the
dorsal curved talar surface can rotate during plantar flexion, a
relative hinge-type motion occurs in dorsiflexion owing to the
flat articular surface, restricting motion.
After the arthrogram, anesthetic and steroid were injected.
Bandaid dressed the puncture.
There were no complications, and the patient left the IR suite in
stable condition. Dr. was present for the entire procedure.
IMPRESSION
Uncomplicated lower back and right ankle injections.
For report below,...haven't coded these hardly....can you give me some input...
For 62311, how many times?..and 77003..although perm.images are not documented?
For the ankle...is it 27648/73615 for injxn.for arthrogram. What about the therapeutic injection into ankle...bundled into 27648?
PROCEDURE: Bilateral L5 medial branch blocks with steroid,
right ankle arthrogram, right ankle anesthetic/steroid injection
HISTORY: 17 year old boy with bilateral Bertolotti lesions and
lower back pain, postoperative right clubfoot with ankle pain.
CONSENT: The risks and benefits, including but not limited to
peristent pain, bleeding and infection were explained to the
patient's mother who gave verbal and written consent. Right ankle
was marked.
PROCEDURE TIME: 45 minutes
MEDICATIONS:
Weight 75kgs
Contrast: 8 ml Omnipaque 300
Kenalog 40 mg over L5 posterior elements
Bupivacaine 25 mg over L5 posterior elements
Aristospan 10 mg in right ankle joint
Ropivacaine 3 mg in right ankle joint
PROCEDURE: The boy was placed prone. The skin of the lower back
region was prepped and draped in sterile fashion . Using
fluoroscopic guidance 4 22 gauge needles were inserted from
dorsal approach over each L5 lamina and each L5-S1 lateral
pseudarthrosis. Once position of the needles was confirmed,
Kenalog 40 mg and Bupivacaine 25 mg with contrast was divided in
four doses were injected . The needles were then removed. The
site was dressed with a Dermabond and tegaderm .
The boy was placed supine.
Right ankle joint anterior aspect was prepped. 22 g needle was
inserted anteromedially. 4 ml of contrast was injected for
arthrography. Flat superior talar surface is seen. While the
dorsal curved talar surface can rotate during plantar flexion, a
relative hinge-type motion occurs in dorsiflexion owing to the
flat articular surface, restricting motion.
After the arthrogram, anesthetic and steroid were injected.
Bandaid dressed the puncture.
There were no complications, and the patient left the IR suite in
stable condition. Dr. was present for the entire procedure.
IMPRESSION
Uncomplicated lower back and right ankle injections.
