Can I bill for medications in addition to RFA?

Hi,

I am attempting to code for an RFA and hope someone will be willing to read this op note and offer guidance:

Radiofrequency Ablation (RFA) of Lumbar Facet Medial Branch Nerves

Procedure Title(s):

1. RFA of Lumbar medial branch nerves on the LEFT and RIGHT side

- performed at the levels of L4,5,Ala levels

2. Intraoperative fluoroscopy

Pre-operative Diagnosis: Lumbar facet arthropathy

Post-operative Diagnosis: Lumbar facet arthropathy

Attending Surgeon: XXXXXXXX, MD

Anesthesia: Local Anesthesia

Name: XXXXXXXXX

DATE: 1/12/2015

INDICATIONS/DIAGNOSIS: Patient is here for today's planned radiofrequency procedure with complaints of low back pain. The patient denies any bowel/bladder dysfunction.

RELEVANT LABS:

PLT'S AUTO 246 07/05/2012

INR 0.97 11/29/2010

Indications: Patient is a 62 year old male with a diagnosis of lumbar facet arthropathy. The patient?s history and physical exam were reviewed. The risks, benefits and alternatives to the procedure were discussed, and all questions were answered to the patient?s satisfaction. The patient agreed to proceed, and written informed consent was obtained.

Informed Consent: The risks, benefits and alternatives to the procedure were discussed, and all questions were answered to the patient?s satisfaction the risks of the procedure including damage to the skin, worsening pain, weakness in the lower extremities, permanent damage to the nerve or spinal cord were presented and discussed with the patient

Procedure in Detail: The patient was brought into the procedure room and placed in the prone position on the fluoroscopy table. The area of the lumbar spine and upper buttocks were prepped with betadine times three and draped in a sterile manner. Attention was then first turned toward performing the RF at the lumbar medial branch of L4, An oblique fluoroscopic image was used to identify the target junction point where the SAP and the TP of the vertebral body fuse. The skin and subcutaneous tissues with 5cc of 1% lidocaine. A 20-gauge, 100 mm radiofrequency probe was advanced toward the target point under intermittent fluoroscopic guidance. Once bone was contacted, negative aspiration was confirmed. Sensory stimulation was performed at 50 Hz and 0.4 volts, generating a pressure sensation. Motor stimulation at 2 Hz and 1.2 volts was negative for lower extremity movement but associated paraspinal twitch was prsent. 1ml of 1% lidocaine was injection prior to lesioning, which was performed for 90 seconds at 90 degrees centigrade. Please see MA note for impedances. Once the lesion was complete, 2ml of a solution consisting of 4ml of 0.5% bupivacaine and 1ml triamcinolone (40mg/mL) was injected through each probe. The probes were removed with a 1% lidocaine flush.

Identicle procedures where performed at the other lumbar medial branch levels

I have a couple of questions, first, is this note complete enough to code at all? If it is, I come up with codes 64635-50 and 64636-50. Secondly, can I pick up the J3301 for the Kenalog?

Any/all assistance will be much appreciated !

Can I bill for medications in addition to RFA?