Wiki Transforaminal injections

[coderguy1939]

On the op report under Procedures, the doctor states right-sided transforaminal injections at L3-L4, L4-L5, & L5-S1. In the Procedure in Detail, the doctor does not include information as to which side he is injecting or at what levels. He just refers to "each respective joint" and Depo-Medrol "was injected without complication at each of the respective levels". Can this be coded as right-sided injections if the details are not included in the Procedure in Detail? Thanks for your input.

 

[magnolia1]

I would request an amended procedure note.

 

[jessieindiego]

But you said in the report he stated right-sided. I would say it's the right side. We code for left and right trans injections.