Wiki Required documentation in Procedure Note for TESI?

[chriscottd]

Is there any language around the required elements in a Procedure in Detail note? I have a record I am reviewing that is stated to be an L4-5 B TESI in procedure header; but the procedure in detail note mentions the spinal needle "advanced towards the 6 o'clock position of the pedicle at L4-5 and L5-S1 on the right." Then 0.5 mL of contrast injected "reveled spread along the nerve root." no uptake seen...then injected with lidocaine and betamethasone at each level.

 

[dwaldman]

L4-5 B TESI in procedure header; but the procedure in detail note mentions the spinal needle "advanced towards the 6 o'clock position of the pedicle at L4-5 and L5-S1 on the right." Then 0.5 mL of contrast injected "reveled spread along the nerve root." no uptake seen...then injected with lidocaine and betamethasone at each level.

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I would request the procedure heading and what was performed to match through an addendum to the record.

I would look at what was ordered to be performed and what was consented for:

It appears the narrative section of the note describes CPT 64483 64484 on the right side being performed. The procedure heading though, describes potentially 64483-50????

 

[chriscottd]

L4-5 B TESI in procedure header; but the procedure in detail note mentions the spinal needle "advanced towards the 6 o'clock position of the pedicle at L4-5 and L5-S1 on the right." Then 0.5 mL of contrast injected "reveled spread along the nerve root." no uptake seen...then injected with lidocaine and betamethasone at each level.

________________________________
I would request the procedure heading and what was performed to match through an addendum to the record.

I would look at what was ordered to be performed and what was consented for:

It appears the narrative section of the note describes CPT 64483 64484 on the right side being performed. The procedure heading though, describes potentially 64483-50????

The CONSENT! Awesome!! Thanks...

So, you do see enough info to bill an epidural?

 

[dwaldman]

The procedure note is sufficient documentation to bill for the procedures performed, but it is important to request the heading match the narrative section.