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
- ICD-10 Training
- Exam Preparation
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join