Sample Chart 1
EXAM DESCRIPTION: IR spine myelogram cervical
CLINICAL HISTORY: Neck pain, intrathecal injection for CT cervical spine (CT cervical myelogram)
CONSENT: The procedure, risks, benefits, and alternatives were discussed with the patient, and all questions were answered. Informed consent was obtained verbally and in writing.
NURSING/MEDICATIONS: Continuous cardiorespiratory monitoring was provided throughout the examination. Moderate conscious sedation at level 3-4 was obtained with versed and fentanyl by a trained independent observer under the supervision of the performing provider.
FINDINGS: The patient was positively identified, taken to the angiography suite, and positioned prone on the fluoroscopy table. Timeout was performed.
LP performed at L3-L4 with a 22 gauge needle. Fluid is clear.Contrast was injected under fluoroscopic guidance confirming intrathecal location. Patient was in placed supine for 10 minutes prior to CT scanning
Complications: None immediate.
Disposition: The patient tolerated the procedure well and left the angiography suite in stable condition. The patient was returned to the recovery location for further observation.
Estimated blood loss: 0
Fluoroscopy time: 1.2 minute
IMPRESSION:
- Successful lumbar puncture for the installation of intrathecal contrast for CT myelogram
CPT: 62302 Myelography via lumbar injection, including radiological supervision and interpretation; cervical
Sample Chart 2
EXAM DESCRIPTION: Right L5 and S1 Transforaminal Epidural Steroid Injection
Anesthesia: Local
Pre-procedure diagnosis: Lumbar DDD, Lumbar Radiculopathy Post-procedure diagnosis: Lumbar DDD, Lumbar Radiculopathy Physician Confirmed and marked the surgical site.
CONSENT: The patient has undergone the educational process regarding this procedure and is aware of, and fully understands, the risks involved: pain, failure to relieve pain, infection, bleeding, nerve
damage, headache, seizure, medication reaction, permanent neural injury or paralysis, potential damage to any and all body organs. Patient also understands that the procedure will be undertaken in a
safe, controlled and monitored setting. Patient recognizes that the benefits include relief from pain and reduction in the oral use of medications. Patient also understands alternative treatments include,
physical therapy, medications, surgery and to do nothing. All questions were answered and patient agreed to proceed. Patient identified and pre-procedural Time-Out completed.
PROCEDURE IN DETAIL: The patient was placed in a prone position. The back was prepped and draped with chloraprep x 2 in usual sterile fashion. In an anterior oblique fluoroscopic view, the pedicle corresponding to the aforementioned level was easily identified. A point just below the six o’clock position of the pedicle was injected with 2mL of 1% lidocaine for local anesthesia. A 22ga spinal needle was advanced under incremental biplanar fluoroscopic guidance until the tip of the needle was seen entering the superior aspect of the neuroforamen. Under live fluoroscopy 2mL of Isovue 200M contrast was injected and the pattern of spread was consistent with proper epidural spread, outlining the exiting nerve root, and negative for subdural and vascular uptake. After negative aspiration for blood and CSF a mixture of 5mg dexamethasone in 3mL of PF normal saline was then slowly injected at each level. For bilateral procedures the same exact procedure was then completed for the opposite side. The needle was styletted and removed.
For the S1 level: Under a/p fluoroscopic view the S1 foramen was easily seen and 2ml of 1% lidocaine was injected for local anesthesia. A 22ga spinal needle was then advanced under biplanar fluoroscopic guidance until the needle was seen entering the posterior aspect of the epidural space at the level of S1. 2mL of Isovue 200M contrast was then injected, which demonstrated a pattern consistent with epidural spread and was negative for vascular or subdural uptake. Next, 5mg dexamethasone in 5mL of PF normal saline
was injected. The needle was styletted and removed.
CPT code: 64483 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level
64484 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
Sample Chart 3
EXAM DESCRIPTION: US fna thyroid
CLINICAL HISTORY: Right thyroid gland nodule
COMPARISON: 03/17/2021
TECHNIQUE: We explained the procedure to the patient. We discussed the risks, benefits and alternatives. We specifically discussed the risks of pain, bleeding, infection, and damage to nerves, vessels or other underlying structures, specifically including the risk of injuring the carotid artery or the jugular vein. We answered all the patient’s questions. The patient agreed to proceed and signed informed consent.
We performed a procedural pause to confirm the patient’s identity and the intended procedure. We imaged the patient’s right neck and identified a small 0.7 x 0.3 by 0.6 cm hypoechoic mass within the right thyroid gland.
The skin was marked. The patient’s skin was cleansed with chlorhexidine and a sterile barrier created with sterile drapes. Hand hygiene was performed and sterile gloves were utilized. A sterileultrasound probe cover was utilized.
Under ultrasound guidance, we anesthetized the skin and subcutaneous soft tissues. Under ultrasound guidance, we obtained 3 fine needle aspirations using 25-gauge needles. We obtained ultrasound images demonstrating the needles entering the mass.
The pathologist indicated that the specimen was adequate. We placed a sterile. The patient tolerated the procedure well without immediate postprocedural complication.
SPECIMENS: 25 gauge fine-needle aspiration samples x3.
ESTIMATED BLOOD LOSS:Minimal
COMPLICATIONS:None immediate
IMPRESSION:
- Technically successful ultrasound guided fine needle aspiration of a small 0.7 cm hypoechoic nodule within the right thyroid gland.
- Please note the right thyroid gland nodule previously demonstrated on the CT neck head significantly decreased in size in the interim with going from 1.4 to 0.7 cm.
CPT : 10005 Fine needle aspiration biopsy, including ultrasound guidance; first lesion
