ok all of my spine FRIENDS!! I need help. I have a provider challenging my coding.
Would you code the following with 64640 x1 or 64640 x9??
Can you provide me written documentation for your answer for either scenario?
POSTOPERATIVE DIAGNOSES: 1. Chronic low back pain.
2. Lumbar degenerative disc disease.
3. Lumbar herniated nucleus pulposus.
4. Sacroiliac dysfunction, recurrent.
5. Lumbar postlaminectomy syndrome.
PROCEDURE PERFORMED: Radiofrequency denervation of left sacroiliac joint under fluoroscopic guidance.
DESCRIPTION OF PROCEDURE: The patient was greeted in the OR holding area where consent was verified for today's procedure and his NPO status was confirmed. The procedure site and side was verified and marked with the patient's participation. An intravenous line was started. He was premedicated with Ancef 1 g IV just prior to the procedure. He was then transported to the operating room where he was positioned prone on the x-ray table with appropriate padding. A time-out was taken and monitored anesthesia care was administered by Dr. XXX. The Cosman radiofrequency lesion generation system was prepared for use. A grounding pad was connected to the patient's left lateral thigh. All lesions described in this operative report were generated using 100-mm curved cannulae with the appropriate size electrodes. Prior to all lesion degeneration, there was careful fluoroscopic confirmation of cannula position. Also, continuous impedance monitoring was utilized. The impedance was ranged from 150 to 220 ohms. Prior to lesion generation, motor stimulation was performed at 2 hertz upto 3 volts and at no time there was left lower extremity motor stimulation observed. All lesions described in this operative report were generated to the target temperature of 85 degree celsius for a lesion time of 90 seconds. The left gluteal area was thoroughly prepared with ChloraPrep and draped in the usual sterile fashion.
Using fluoroscopic views in the AP, oblique, and cephalad angulated projections, the left sacroiliac joint was optimally visualized. The skin entry points were selected overlying the structure and 1% Xylocaine was infiltrated into the skin and subcutaneous tissues for local anesthesia. Under fluoroscopic guidance, a total of nine 100-mm radiofrequency cannulae were directed until the needle tip entered the articular portion of the joint. The cannulae were arranged in strip fashion. After careful fluoroscopic conformation of cannula position and negative motor stimulation, lesions were generated based on the above-described parameters. All cannulae were then removed. There was adequate hemostasis noted at the skin puncture sites. The patient's vital signs remained stable. He was able to move all four extremities following the procedure. He was transported to the recovery room in satisfactory condition.
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