Results 1 to 3 of 3

interpretation requested for short infusion note

  1. #1
    Everett, WA
    Default interpretation requested for short infusion note
    Exam Training Packages
    Need help understanding this process:
    IV access was established. Ativan 2 mg was given intravenously by slow IV push. He had an injection of Vistaril 50 mg IM to help with nausea. Additionally he had Toradol 30 mg diluted in 100 cc and infused intravenously starting at 11 AM and ending at 11:20 AM. He had Botox injections and still complained of headaches. Then Nubain 30 mg was diluted in the 100 cc and infused over 30 minutes. Infusion started at 12:40 AM and ended at 1:10 PM. Patient was monitored for two hours.

    This is an in-office procedure performed by the neurologist. I'm only questioning the actual infusion process, and not the botox injections and extracted the above paragraph for help.

    Two coding choices 1)
    96365, 96374, 96372. I do not agree with this.
    2) Since it is in-office we do not need to follow the hierarchal hx coding and am coding presenting for the same diagnosis. 96374 (initial), 96367 (subsequent w Toradol), and additional 96367 (Nubain) , 96372 (Vistaril) with appropriate modifiers.

    I am an expert at asking questions but clueless re clinical aspects of the infusion process and this note just confuses me. Does the Nubain infusion AFTER the botox injections suggest the start of another "initial process?" May have follow-up questions.

    Suzanne E. Byrum CPC

  2. Smile re: interpretation requested for short infusion note
    I would code this scenario as your #2 choice. I also disagree with #1 because you cannot code two "initial" services for this one unless the injections/infusion were given through different IV sites.

    The giving of the Botox injections have no bearing on how you should code the Nubain.

    I hope this helps!!

  3. #3
    Everett, WA
    Thank you for your reply. I was thinking this post might not be answered and I'd have to resubmit. IT's a good way to start out a fresh Monday morning when someone points you in the right direction! ---Suzanne E. Byrum CPC

Similar Threads

  1. A short infusion paragraph to code
    By ollielooya in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 10-20-2011, 12:07 AM
  2. Please help with short op-note
    By coders_rock! in forum Orthopaedics
    Replies: 1
    Last Post: 08-18-2011, 07:47 AM
  3. Please help with short op-note!
    By coders_rock! in forum Orthopaedics
    Replies: 1
    Last Post: 08-17-2011, 02:46 PM
  4. Help coding a short op-note
    By coders_rock! in forum Orthopaedics
    Replies: 2
    Last Post: 08-17-2011, 02:45 PM
  5. Need help with very short chart note
    By ollielooya in forum E/M
    Replies: 2
    Last Post: 04-26-2011, 01:31 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.

Get OurFREE2017SalarySurvey.

We'll email you a link to our 2017 Healthcare Salary Survey when it is available so you can see your earning potential.