The following documentation is from the health record of a 35-year-old female
The following documentation is from the health record of a 35-year-old female? patient. Hospital Outpatient Surgery Services Operative Report Preoperative Diagnosis: Right trigeminal neuralgia Postoperative Diagnosis: Right trigeminal neuralgia Operation: Right radiofrequency coagulation of the trigeminal nerve Indications: This is a 35-year-old female with intractable trigeminai neuralgia causing her considerable pain and inability to eat or speak, and who was referred for treatment of her affliction. indications. potential complications, and risks were explained to the patient and family. Operative Procedure: After the patient was positioned supine, intravenous sedation with propofol was administered. Lateral skull x-ray fluoroscopy was set. The right cheek was infiltrated derrnally with Xylocaine. and a small nick in the skin 2.5 cm lateral to the corner of the mouth was made with an 18-gauge needle. The radiofrequency needle with 2-mm exposed tip was then introduced using the known anatomical landmarks and under lateral fluoroscopy guidance into the foramen ovale. Confirmation of the placement of the needle was done by the patient grimacing to pain and by the lateral may The first treatment, 90 seconds in length, was administered with the tip of the needle 3 mm below the clival line at a temperature of 75°C. The needle was then advanced further to the midclival line and another treatment of similar strength and duration was also administered. Finally, the third and last treatment was administered with the tip of the needle approximately 3 cm above the line. The cerebrospinal fluid was noted. The needle was removed. The patient tolerated the procedure well and had adequate tearing and corneal sensation and had reduction. if not complete cure. of her pain by the end of the procedure. Which of the following ICD-1 0-CM and CPT code sets is correct? a. G500. 64600 b. G500, 64610 c. (350.0, 64615 d 650.0, 64605
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