How would you code this procedure? 20550? Or 64405 or 64450?
I'm leaning towards 64405, but Dr. wants to code 20550?
Melinda Brown, CMBS
Pt was just in on 1/24/13 for an E/M w/migraine headache & then came
back on 1/30/13.
Subjective: After the hydrocodone and the dexamethasone her headache got
better for almost 24 hrs. Then it recurred and has slowly been coming
back and now is back in full force. She tried another course of the
hydrocodone and dexamethasone and she had a brief reprieve but the
headache has been back full force these past two days. The headache
begins on the right side of her occiput and radiates to her right
temple. The pain is steady and throbbing and she rates it as a 9/10.
She has no associated sinus pressure or drainage, no significant nausea
or photo or phonophobia. Her neck feels stiff and sore "like somebody
Objective: Pt is unkempt. She has difficulty extending and turning and
flexing her neck, especially turning to the right side. She has a
point tender area at the base of her skull on the right side where
pressure seems to reproduce her pain.
Assessment: Occipital neuritis is what appears to be the cause today.
Plan: I injected the point tender area with 10 mg of kenalog and 1.5
cc's of xylocaine . After a rest she is slightly better. Let's give
her Demerol 100 mg and Vistaril 25 mg IM and ask that she go home, go to
bed, apply ice or heat (her choice) and then call us this afternoon.
Demerol 100 mg/vistaril 25 mg IM LOUQ given.
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