Question

Procedure performed in the office.

PREOPERATIVE DIAGNOSIS : Right-sided thoracic pain.

POSTOPERATIVE DIAGNOSIS : Right-sided thoracic pain.

OPERATION : Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles.

PROCEDURE :

The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed.
I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 ccs (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding.
We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

CPT® Code Reported: 20552

ICD-10-CM Code Reported: M54.6 (Thoracic Spine Pain)

Step-by-step explanation:

The CPT® code 20552 corresponds to the trigger point injection procedure described in the documentation. This code is used for the injection of a single or multiple trigger points in one or more muscles. In this case, the injection was performed into the rhomboid major, rhomboid minor, and levator scapular muscles on the right-sided thoracic spine.

The ICD-10-CM code M54.6 is appropriate for reporting the preoperative and postoperative diagnoses of right-sided thoracic pain. This code specifically captures pain in the thoracic spine region, aligning with the patient's symptoms and the targeted area for the trigger point injections.

It's crucial to select the most accurate codes to ensure proper reimbursement and documentation of the procedure. The provided codes reflect the procedural and diagnostic details outlined in the medical report. Additionally, the opioid contract and pain medication management are essential components of patient care in the context of metastatic lung cancer, emphasizing the comprehensive approach to pain management for individuals with complex medical conditions.