Blackhorse Posted Fri 05th of January, 2018 19:39:56 PM
Impression Left shoulder impingement syndrome. Left AC joint arthritis Right rotator cuff tear
Plan/Recommendation I had a long discussion with the patient today concerning their diagnosis, diagnostic studies, natural history and treatment options. I have advised for conservative management including ice, pain medication as needed, modification of activities, and home exercises. I cautioned against repetitive motion above shoulder height, lifting heavy objects or reaching above shoulder height. I emphasized range of motion and stretching exercises at home.
I have also discussed the clinical indications for steroid injections and the patient elected to proceed forward with the steroid injection. After informed consent was obtained the patient's left shoulder was prepped with Chlorhexidine solution. 6 cc of quarter percent Marcaine plain and 12 mg of Celestone was then injected into the subacromial space without difficulty. The patient tolerated the procedure well and there were no apparent complications. Post injection instructions were given. An ultrasound Sonosite laptop with variable frequency linear transducer was used to localize the placement of a 22-gauge needle to confirm proper placement in the joint space. The patient is to follow-up as necessary.
I have also discussed conservative management for his right shoulder until his surgery as well.
20611 was denied by UHC because of lacking permanent image information for ultrasound. I checked with my manager, we don't have any image saved for ultrasound guidance. Are you supposed to save the image for ultrasound or documentation is sufficient?
SuperCoder Answered Mon 08th of January, 2018 05:31:40 AM
CPT code 20611 will require ultrasound guidance, with permanent recording of images and reporting, simply documenting ultrasound in records will not be sufficient. However, to get the services billed and avoid any denials we can go for lower code such as 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. Hope it helps.