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Wiki Transforaminal injections

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coderguy1939

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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.
 
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