dyoungberg
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I was wondering if anyone out there has had experience in coding this type of procedure and could offer some assistance. Here is the operative note:
PREPROCEDURE DIAGNOSIS: OCCIPITAL NEURALGIA, CERVICAL FACET DISEASE
POSTPROCEDURE DIAGNOSIS: SAME
PROCEDURE:
1. THERAPEUTIC RADIOFREQUENCY PULSED LESIONING FOR THE DORSAL ROOT GANGLION OF C2 ON THE RIGHT
2. RHIZOTOMY OF THE MEDIAL BRANCH OF C3 ON THE RIGHT
3. FLUOROSCOPY
ANESTHESIA: MAC (MINIMAL)
COMPLICATIONS: NONE
PROCEDURE IN DETAIL: After obtaining the consent form, the patient was taken to the procedure room (fluoroscopy suite) where the patient was placed on the fluoro table in the supine position. The neck area was prepped with Betadine and draped in sterile fashion. Using the C-arm, PA and lateral view, the C1 and C2 vertebral space was identified. The skin was infiltrated subcutaneously with 1% Xylocaine. A 22G RFK 5 mm needle was advanced at the tip of the skin toward the space between C1 and C2. Under AP view, the needle was advanced medially and by using open-mouth technique the space between C1 and C2 was identified. The needle was advanced medially and it was located in the space in the lateral third of the vertebral body. At this moment, sensory stimulation showed reproduction of the patient's pain in the back of the head and the top of the head at less than 0.5 millivolts. Motor stimulation showed no movement in any part of the extremities. There was no stimulation around the ear area and there was no stimulation in the face area. Subsequently, lesioning was done at 42 degrees for 90 seconds then the needle was removed. The patient tolerated this part of the procedure with no complications.
Then, by obtaining an oblique view, we identified the rest of the vertebra at C2. We infiltrated the skin and subcutaneous tissue with 1% Xylocaine. We then advanced a 22G RFK 5 mm needle at the tip from the scalp towards the body of the facet joint at C2. We slide the shaft of the needle against the waist of the facet joint. This was confirmed by AP and lateral view and oblique view. Sensory stimulation was done which showed reproduction of the patient's pain in the back of the neck and top of the head. There was no stimulation or sensory stimulation around the ear or in the face area. Motor stimulation was done for up to 3 ampere which shows no movement of the upper extremities. Then, lesioning was done at this location at 42 degrees for 90 seconds. A mixture of 4 cc normal saline and 1 cc Decadron was injected and then the needle was removed. The patient tolerated the procedure very well without complication. The patient was observed in the recovery room and was discharged in a stable condition. The patient was advised to call immediately if they notice any change in symptomatology or fever and go to the nearest emergency room. The patient will be seen in the office in one week for follow up or earlier if needed.
I appreciate any assistance with this.
PREPROCEDURE DIAGNOSIS: OCCIPITAL NEURALGIA, CERVICAL FACET DISEASE
POSTPROCEDURE DIAGNOSIS: SAME
PROCEDURE:
1. THERAPEUTIC RADIOFREQUENCY PULSED LESIONING FOR THE DORSAL ROOT GANGLION OF C2 ON THE RIGHT
2. RHIZOTOMY OF THE MEDIAL BRANCH OF C3 ON THE RIGHT
3. FLUOROSCOPY
ANESTHESIA: MAC (MINIMAL)
COMPLICATIONS: NONE
PROCEDURE IN DETAIL: After obtaining the consent form, the patient was taken to the procedure room (fluoroscopy suite) where the patient was placed on the fluoro table in the supine position. The neck area was prepped with Betadine and draped in sterile fashion. Using the C-arm, PA and lateral view, the C1 and C2 vertebral space was identified. The skin was infiltrated subcutaneously with 1% Xylocaine. A 22G RFK 5 mm needle was advanced at the tip of the skin toward the space between C1 and C2. Under AP view, the needle was advanced medially and by using open-mouth technique the space between C1 and C2 was identified. The needle was advanced medially and it was located in the space in the lateral third of the vertebral body. At this moment, sensory stimulation showed reproduction of the patient's pain in the back of the head and the top of the head at less than 0.5 millivolts. Motor stimulation showed no movement in any part of the extremities. There was no stimulation around the ear area and there was no stimulation in the face area. Subsequently, lesioning was done at 42 degrees for 90 seconds then the needle was removed. The patient tolerated this part of the procedure with no complications.
Then, by obtaining an oblique view, we identified the rest of the vertebra at C2. We infiltrated the skin and subcutaneous tissue with 1% Xylocaine. We then advanced a 22G RFK 5 mm needle at the tip from the scalp towards the body of the facet joint at C2. We slide the shaft of the needle against the waist of the facet joint. This was confirmed by AP and lateral view and oblique view. Sensory stimulation was done which showed reproduction of the patient's pain in the back of the neck and top of the head. There was no stimulation or sensory stimulation around the ear or in the face area. Motor stimulation was done for up to 3 ampere which shows no movement of the upper extremities. Then, lesioning was done at this location at 42 degrees for 90 seconds. A mixture of 4 cc normal saline and 1 cc Decadron was injected and then the needle was removed. The patient tolerated the procedure very well without complication. The patient was observed in the recovery room and was discharged in a stable condition. The patient was advised to call immediately if they notice any change in symptomatology or fever and go to the nearest emergency room. The patient will be seen in the office in one week for follow up or earlier if needed.
I appreciate any assistance with this.