Want to test your coding skills? Try your head hand at selecting the correct diagnosis and procedure codes for these three headache treatments and put your answers in the comments.
Headache treatment #1
Diagnosis: Chronic post-traumatic headache, intractable
Procedure note: The patient was placed in a sitting position. The skin was prepped with alcohol prior to needle placement. Using a 25-gauge, 1.5 inch needle, a left greater occipital never blockade was performed by injection 2 cc of a combination of 3.0 cc 0.5% bupivacaine and 40 mg Depo-Medrol. By manipulating the needle, the left lesser occipital nerve was injected with the remaining 2 cc of the mixture. The patient tolerated the procedure well, was given post-procedure instructions and discharged in good condition. Practice has contract that will pay for bupivacaine.
Headache treatment #2
Diagnosis: Tic douloureux with chronic pain
Procedure note: The 34-year-old patient had a very positive response to two separate left diagnostic anesthetic injections of the trigeminal nerve and wishes to proceed with a denervation procedure. Moderate sedation was provided, injecting Midazolam 4 mg and fentanyl 100 mcg. The procedure was performed under fluoroscopic guidance with the patient in the supine position and head extended. The C-arm was rotated to obtain an oblique submental view to visualize the foramen ovale. The skin entry point was 3 cm lateral to the commissura labialis on the affected side. The needle trajectory followed a straight line directed toward the pupil and passed 3 cm anterior to the external auditory meatus.
A 22-gauge, 10-cm RF cannula with a 5-mm active tip was used. After administration of local anesthesia with 1% lidocaine, the cannula was advanced in a coaxial manner to the X-ray beam toward the foramen ovale. A finger was placed in the oral cavity verified that the buccal mucosa had not been perforated. The depth of the cannula inside the Meckel’s cavity was ascertained on the lateral fluoroscopic view. The electrode was advanced 3 mm further through the canal of the foramen ovale such that the tip of the electrode reached the junction of the petrous ridge of the temporal bone and the clivus. The stylet was removed from the cannula, and aspiration was performed, demonstrating that there is no CSF or blood. Then 0.5 mL Isovue-300 contrast dye was injected to confirm that the needle had not penetrated the dura.
Test stimulation was performed at 2 Hz between 0.1 and 1.5 Hz and muscle contraction of the lower jaw was noted, confirming that the needle has passed through the foramen ovale and the tip is lying on the trigeminal roots. Paresthesia in the concordant trigeminal II division occurred at 50 Hz, 1 msec at 0.2 V. After all appropriate stimulation parameters were achieved, 0.5 mL of 0.25% bupivacaine with 40 mg of triamcinolone was injected. After waiting for 30 sec, RF lesioning at 60°C was carried out for 60 sec. The needle was repositioned to repeat RF lesioning at third division. The patient tolerated the procedure well and was transported to the recovery area. Hard copies of the fluoroscopic images were printed and placed in the patient’s record. Total face-to-face time for moderate sedation was 23 minutes.
Headache treatment #3
Diagnosis: Chronic migraine without aura, intractable, without status migrainosus
Procedure note: The skin over the treatment area was prepped with alcohol. Vacuum dried powdered onabotulinumtoxin A 200 units in a single use vial was reconstituted with 4 ml preservative free 0.9% sodium chloride per manufacturer’s specification. Using a 30 gauge 0.5 inch needle, with needle electromyographic guidance, a total of 155 units (0.1 ml=5 units) of onabotulinumtoxinA was injected at 31 points including corrugator muscle (10 units/2 sites), procerus muscle (5 units/1 site), frontalis muscle (20 units/4 sites), temporalis muscle (40 units/8 sites), occipitalis muscle (30 units/6 sites), cervical para-spinal muscle group (20 units/4 sites) and trapezius muscle (30 units/6 sites). Patient tolerated the procedure well. She has some mild ptosis noted in left eyelid but it did not obstruct vision. 45 units of onabotulinumtoxinA was wasted as per office policy.