Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nnSubjective:nnChief Complaints:n
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- Bilateral L5/Sl TF Epidural PRP. Nosed. No ABX/AC. PM.
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nMedical History:nnMedications: Taking Baclofen 10 MG Tablet TAKE ONE-HALF TO ONE TABLET BY MOUTH AT BEDTIME , Taking Celecoxib 200 MG Capsule TAKE ONE CAPSULE BY MOUTH TWICE DAILY, Taking Belbuca 150 MCG Film 1 film to the gum Buccally every 12 hrs, Notes: DNF: 07/29/19, next due 08/28/19, Taking Oxycodone-Acetaminophen 5- 325 MG Tablet 1 tablet as needed Orally every 12 hrs, Notes: DNF: 07/29/19, next due 08/28/19nnObjective:nnVitals: BP 122/78 mm Hg, HR 92 /min, Ht 71.0 in, Wt 195 lbs, Oxygen sat% 95 %, BMI 27 .19 Index.nnAssessment:n
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- Lumbar spondylosis – M47 .816 (Primary)
- Lumbar radiculopathy – M54.16
- Degeneration of lumbar intervertebral disc – M51.36
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nAt this point, patient has failed conservative therapy, has undergone imaging and physical examination which demonstrate facet mediated pain.nnThey also have undergone dual diagnostic MBB with over 80% relief on DOS and the duration of effect was consistent with the local anesthetic used.nnThey have had prior RFA of the same levels (over 6mo ago) with >60% relief for 4mo and, by their report, had improvement in performance of ADLs of home, work and family.nnPlan:n
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- Others
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nNotes:nnFAILURE OF CONSERVATIVE MANAGEMENT OF OVER 4 WEEKSn
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- Prescription strength anti-inflammatory medications and analgesics
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants
- Physician-supervised therapeutic exercise program or physical therapy
- PAIN SEVERITY IS 3/10 OR GREATER
- UNABLE TO PERFORM AOL’S of WORK, HOME,and RECREATION,
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nProcedures:nnCPS Procedures:nnPre-op, Diagnosis: Lumbar Radiculopathy and disc degeneration.nnPost-op. Diagnosis: same.nnInformed Consent: The risks and benefits per the informed consent were discussed with the patient.nnAlthough risks are theoretically possible, they are remote. We specifically discussed infection, bleeding, nerve damage, spinal cord damage and paralysis. Patient understands risks and benefits and wishes to proceed. All questions answered..nnProcedure: Bilateral LS/S1 TRANSFORAMINAL EPIDURAL, LS/S1 FACET and LEFT APPROACH Discogram and INJECTION of PLATLET RICH PLASMA .nnSedation : None.nnDetails of Procedure: First 60mL of the patient’s blood was sterll collected from the LEFT AC and processed per Celling Biosciences PRP kit instructions. Strict aseptic technique was maintained. 500 mg ancef was given IV. The patient was placed prone on the fluoroscopy table. after sterile prep and drape with chlorhexidine, C-arm fluoroscopy was used to visualize the lumbar spine. The skin puncture sites were anesthetized with cold spray. Pt placed in the prone position on procedure table. Monitors were applied.nnThe patient’s back was prepped with chloraprep and draped with sterile towels. Using AP, lateral, and oblique fluoroscopy, the neuroformina were identified. After anesthetizing the skin with bicarbonated 1% lidocaine, a 22 G 5 inch quincke needle was advanced into each neuroforamen. Needle tip position was confirmed on lateral view and with the injection of 0.5 cc of Isoview 200. The left needle was then advanced into the disk and confirmed with omnipaque/ancef mixture. Then each needle was redirected to the LS/S1 facet. The inferior aspect of the joint was accessed. ‘ After negative aspiration, injectate of PRP iML was injected through each needle without difficulty at each location ‘ ‘The patient tolerated the procedure very well..nnComplications: None.nnSpecimens: None.nnImpressions: The patient stayed in the recovery room without motor and sensory deficits and was discharged home with an escort.nnTechnically successful block. Follow up in 30 days,