I have an ortho provider who is refusing to document his procedure further than "today we injected the knee with 40mg kenalog" I am trying to explain to him that any and all procedures should include at minimum: 1) Indications for procedure (medical necessity) 2) Anesthesia/Medication given (include dosage) 3) What was done with some detail site, approach, equipment used, findings 4) Closure of wound (if appropriate) 5) Any complications 6) Patient’s condition at end of procedure. He wants something from the aaos or cms stating this is required and for the life of me I cannot locate guidelines that clearly support any or all of these item. Our templates in the system are built to include this info but he is not using them.
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Tag Archives: Injections
PRP Injections 0232T
Does anyone have any experience in coding PRP injections? I work in an ASC and I wanted to know how many injections are included in the 0232T since the code indicates injection (s). We have a case with 2 kits and both injections were bilateral. Any information would be helpful!
ASC Charges – Epidural injections
I work for an orthopedic outpatient surgery center. One of our physician’s is wondering about billing for epidural steroid injections to the facility. If a bilateral epi is done (64483), do we bill 64483 twice for the facility or would there just be one bulk facility fee?
We were also wondering if multiple levels are injected, are both 64483 and 64484 reimbursable through the facility? Any input is greatly appreciated.
We were also wondering if multiple levels are injected, are both 64483 and 64484 reimbursable through the facility? Any input is greatly appreciated.
Sally Cookman, CPC, COSC
Lumbar Interlaminar vs Lumbar Transforaminal ESI Injections
To Whom It May Concern,
I need some help with a Pain Management procedure. What key words do I need to look for in a procedure note to differentiate between a Lumbar Interlaminar ESI Injection (CPT 62323) and a Lumbar Transforaminal ESI Injection (CPT 64483) so it can be coded accurately?
Below is the providers procedure note for review:
Procedure: Lumbar Epidural Steroid Injection under fluoroscopy.
Diagnosis: Lumbar Degenerative Disc Disease
The patient was evaluated and the procedure risks, benefits and alternatives were discussed with the patient. Informed consent was then obtained.
.
The patient was taken into the procedure room and was placed prone on the table. Skin was prepped with chloraprep and draped in a sterile manner. Sterile technique was observed throughout the procedure. Fluoroscopy was used to identify the targeted L4-5 L5-S1 interspace. Using a 25 gauge needle 5cc of 1% lidocaine was used to achieve adequate local anesthesia.
A 20 gauge epidural needle was advanced into the epidural space under fluoroscopic guidance utilizing the loss or resistance technique[/COLOR][/COLOR]. No parasthesias were noted. After negative aspiration 1 ml of 300 omnipaque was injected. Contrast was confirmed in the epidural space via fluoroscopy. Methylprednisolone [ ] mg mixed with [ ] ml normal saline was slowly injected. The needle was removed intact. The patient remained awake and communicative throughout the procedure with no complaints of pain on injection.
The patient received 50-60% relief from this procedure.
The patient tolerated the procedure well and was transferred to the recovery area without complication and was discharged home after remaining stable during observation.
Appreciate your help.
Thank you.
Lauren
Injections and E/M
:confused:Please help I am confused example
Patient is scheduled just for a follow up visit for knee during the exam has increase pain in knee which is documented steroid injection was discussed and documented as a separate office procedure. Do we bill just an office visit? Do we bill just the injections? Thank you
Patient is scheduled just for a follow up visit for knee during the exam has increase pain in knee which is documented steroid injection was discussed and documented as a separate office procedure. Do we bill just an office visit? Do we bill just the injections? Thank you
HRT injections in FQHC setting
I work for an FQHC in California and there are so many limitations on the codes we can bill for etc. I was wondering if anyone could please share any resources they may know of regarding FQHC’s being able to bill for Hormone Replacement Therapy injections in a sort of group type setting vs. the typical face to face encounters. I can’t seem to find out any info that relates to both the visit type in an actual FQHC clinic. Please any information or resource you could direct me to would be greatly appreciated. Thank you in advance!!
Risperidone injections in office visit – diagnosis code?
I’m having trouble coming up with a primary DX for this type of encounter.
Would I use ICD Z51.81 for visits where the patient comes in for re-evaluation of Schizophrenia, and the medical provider decides to administer Risperidone?
The same provider also addressed anxiety, tobacco use, and upon examination, found a serous bullae.
Would I use ICD Z51.81 for visits where the patient comes in for re-evaluation of Schizophrenia, and the medical provider decides to administer Risperidone?
The same provider also addressed anxiety, tobacco use, and upon examination, found a serous bullae.
Right now I have this, but I’m thinking this will get denied because the primary DX is a mental health disorder:
99213 —- F25.1, F41.9, Z72.0, L13.8
96372 —- F25.1
Prolotherapy/Stem Cell joint injections
Has anyone had any luck with what procedure codes to bill out regarding PRP/Stem Cell Injections for different joints? Our pain management provider is about to start billing these codes. Research I have found so far show:
M0076 HCPCS
0232T CPT
0481T CPT
M0076 HCPCS
0232T CPT
0481T CPT
Do I bill these in conjunction with each other? 20999 looks incorrect to bill with 0232T.
Procrit injections
Good morning,
I think I know the answer to this, but we are looking for confirmation.
Does your office do Procrit injections, and if yes, does your PA do the injections? How do you submit your billing? Is it billed under the PA’s name, or under the provider’s name? Who signs the note?
thanks in advance!
joint injections during the global period
Question:
can 20610-79 be reported when the doctor performs a joint injection following a surgery if the patient comes for pain after one week or a month out from surgery.
thanks