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Aborted pacemaker placement

Hi, I could use some advice on this please. Would you bill this as a pacemaker placement 33207 with a 53 modifier along with a Venography? I appreciate the info.

PROCEDURE: Venogram was done on the right and left side-patent venous system was confirmed. The patient was prepped and draped in the usual sterile fashion. Access was gained into the left axillary vein after venography and fluoroscopy-first with a micropuncture wire and then with a regular wire. Right sided placement was confirmed after passing the wire below the diaphragm. The prior incision (made at the outside hospital was opened). The two wires were brought out of the incision.
**
The ventricular lead was advanced directly via a 7 Fr long sheath and positioned in the right ventricular mid septum under fluoroscopy. Lead characteristics were measured and were satisfactory. After I split the sheath there was copious bleeding seen. These occurred to have an arterial pulsation and were seen around the lead as well as in an area more lateral and inferior to the lead. I placed several purse-string sutures around the lead and cauterized other areas that appeared to be bleeding. Hemostasis could not be achieved.
*
I finally called the cardiac surgeons, who also placed purse string sutures around the lead with no effect.
*
After a long discussion about possible causes, that included damage to an arterial branch around the vein, or the main axillary artery itself, I decided to pull out the lead. Hemostasis was finally obtained by manual compression with gauze. Using a staged approach, compression was gradually released and hemostasis was confirmed. The wound was closed by the surgeon-please see his note for details.

Medical Billing and Coding Forum

Ureteroscopy with laser lithotripsy and stent placement question

I think I am correct on this, but I just want to double check.

Urologist did a cystoscopy with right ureteroscopy and laser lithotripsy, with bilateral stents placed. Am I correct to code this as 52356-RT and 52332-59LT? My reasoning is that only the stents are bilateral; the ureteroscopy and laser litho were right-sided only.

Thanks!

Medical Billing and Coding Forum

Hemicraniectomy for Placement of Frontal External Ventricular Drain

I was hoping to get some advice on an op note I’m working on. I’m going between 2 codes.

[I]PREOPERATIVE DIAGNOSIS: Right hemisphere cerebral edema
**
POSTOPERATIVE DIAGNOSIS: Same
**
PROCEDURES: Right Hemicraniectomy
Placement of right frontal external ventricular drain
Use of intraoperative ultrasound
**
INDICATIONS: Joyce Irene Wittenborn is a pleasant 65 y.o. with a history of a brain abscess which we evacuated 2 nights ago. She initially was neurologically stable, but declined today. A repeat CT scan was performed demonstrating a marked increase in the degree of cerebral edema surrounding her evacuated abscess. The patient was taken emergently to the OR for decompression.
PROCEDURE IN DETAIL: The patient was brought to the OR and placed under general anesthesia and then positioned supine on the operating table with his head affixed in a Mayfield headrest in reverse Trendelenburg position. The ipsilateral side of the head pre-prepped with alcohol, and then a small strip of hair clipped and a question mark style incision incorporating the inferior half of her previous linear middle fossa incision was drawn out and infiltrated with 1% lidocaine with epinephrine. The entire area was prepped with ChloraPrep and draped off in sterile fashion. A time out was performed. The patient was already receiving multiple IV abx.
**
The scalp incision was opened and Raney clips used then the scalp was retracted using elastic hooks and a Layla bar. Burr holes were placed then a large hemicraniectomy performed with a craniotome. Strict epidural hemostasis was achieved then the dura opened in flap fashion. Onlay surgicel was used. Surgicel and suprafilm were placed under the exposed temporalis. Using intraoperative ultrasound, a right frontal antibiotic impregnated EVD was placed to a depth of 6.5 mm with spontaneous egress of csf under mild to moderate pressure. A 10mm flat JP drain placed subdurally and tunneled posteriorly. The scalp was closed in standard fashion using Vicryl followed by Vicryl Rapide.The wound was dressed in sterile fashion. There were no apparent complications during the case.
*
Usually when drains are placed they only perform burr holes but he does burr holes along with a hemicraniectomy.
I was wondering if I should just go ahead and use the burr holes for EVD placement (61210) or would Craniectomy for drainage of intracranial abscess (61320) be more appropriate?
The patient does have a history of a brain abscess and then ended up developing a cerebral edema around it.
I just want to make sure that I’m using the best code for this situation.

Thanks in advance for any help!

Medical Billing and Coding

Ct needle placement for embolization of aaa

How would I code for the placement of these needles into the edge of the aneurysm sac prior to embolization?

CT Abd/pelvis with IV was done confirming the presence of a type II endoleak. From a left posterior paraspinal approach employing CT fluoro a 17-guage guiding needle was advanced to the edge of the aneurysm sac having a trajectory expected to enter the endoleak. From a more lateral approach a second 17-guage guiding needle was advanced to the edge of the sac having a trajectory expected to enter the sac in a slightly different location. The patient was then transferred to the angiographic suite where the direct sac emboliaztion was subsequently performed which will be separately reported.

Is there a code for the placement of both needles?

Thanks,

Medical Billing and Coding | AAPC Forum

Interceed placement

I was wanting to see if anyone knows if there is a code for the interceed placement. My provider used it in a procedure and I just cannot find a code for it. I have someone telling me it is a mesh so I could add that code, but I just don’t see that it qualifies as a mesh.
Any suggestions are greatly appreciated.

Thank you,
Tracy

Medical Billing and Coding | AAPC Forum

Seton Placement vs I&D of Abcess

I am not familiar with billing placement of seton. Is this only a billable procedure with anal procedures? Can a seton placement and an I&D billed at the same time?
Here is my scenario: (Thanks in advance!)

HPI

Patient is a 17 year old female here today for wound check and concerns for infection

Packing fell out yesterday, unable to re-place it
Lots of green/white/yellow drainage.
Slight smell. *
Top opening is completely closed. *
Frustrated

No allergy to lidocaine with epi. Has been used before. *
**

Patient Active Problem List*
* Diagnosis* Date Noted*
•* Hydradenitis* 09/17/2016*
•* Abscess of skin* 01/28/2015*
•* Acne* 07/15/2014*
•* Immunizations up to date* 07/15/2014*
* * 8/1/16
*
•* Obesity (BMI 30-39.9)* 07/15/2014*

**

Past Medical History

Past Medical History*
Diagnosis* Date*
•* Acne* *
•* ACL injury tear* *
•* Left ankle sprain* *

**

Past Surgical History

Past Surgical History*
Procedure* Laterality* Date*
•* Arthroscopy, knee, dx, w/wo synovial bx (sep proc)* * *
* * torn ACL*

**

Social History

Social History*
**

Social History*
•* Marital Status:* N/A*
* * Spouse Name:* N/A*
•* Number of Children:* N/A*
•* Years of Education:* N/A*
**

Occupational History*
•* Not on file.*
**

Social History Main Topics*
•* Smoking status:* Never Smoker *
•* Smokeless tobacco:* Never Used*
•* Alcohol Use:* No*
•* Drug Use:* Not on file*
•* Sexual Activity:* No*
**

Other Topics* Concern*
•* Not on file*
**

Social History Narrative*
* 7/15/14* Just moved from Arizona.* Moved for family.*
* *
* 10/3/14 Interested in starting an LGBT group in her high school and attending Pride, not sure of a support structure to get this started. Identifies as straight.*
* *
* 8/17/16 Going into senior year. Excited about AP history. Wants to be a history teacher*

Family History
No family history on file.

Review of Systems
Unable to perform ROS
Constitutional: Negative for fever and chills.
Psychiatric/Behavioral: The patient is nervous/anxious.*

*
Objective
*

Vitals

Filed Vitals:*
* 09/19/16 0845*
BP:* 131/73*
Pulse:* 73*
Temp:* 97.3 °F (36.3 °C)*
TempSrc:* Oral*
Resp:* 16*
Height:* 5′ 3" (1.6 m)*
Weight:* 202 lb (91.627 kg)*
SpO2:* 98%*

Estimated body mass index is 35.79 kg/(m^2) as calculated from the following:
* Height as of this encounter: 5′ 3" (1.6 m).
* Weight as of this encounter: 202 lb (91.627 kg).
98%ile (Z=2.07) based on CDC 2-20 Years BMI-for-age data using vitals from 9/19/2016.

Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress.
HENT: *
Head: Normocephalic and atraumatic.
Eyes: EOM are normal.
Pulmonary/Chest: Effort normal. No respiratory distress.
Neurological: She is alert and oriented to person, place, and time.
Skin: Rash noted. She is not diaphoretic.
Intramammary fold with draining wound. Formerly open tract superiorly and inferiorly. Top opening closed and scabbed. Bottom opening draining white pus with pressure.
Significant scarring and smaller comedones surrounding wound
TTP
Psychiatric:
Tearful during procedure but appropriate

Procedure Note
Procedure – Incision and drainage of abcess
PARQA regarding procedure.* Patient wishes to proceed.* Area prepped in a sterile fashion.* Area numbed with 4 mL 1% Lidocaine with epinephrine.* 11 blade scalpel used to lance superior portion of sinus tract.* There was drainage of 3 mL of purulent material from the abcess.* Wound culture not obtained.* Curved hemostat was used to ensure complete drainage of the tract and to open the tract. Wound was then profusely irrigated with 20 mL of sterile saline. Sterile glove cut into 1 inch long strip and passed through the tract using the curved hemostat. Glove strip was tied using surgical knots. The wound was re-irrigated and wiped clean. THe wound was then covered with gauze. There were no complications to procedure.* Patient tolerated the procedure well.* Patient was instructed as below.

*
Assessment and Plan
Patient is a 17 year old female with hydradenitis here for supperative tract.

L02.213 Cutaneous abscess of chest wall
L70.0 Acne vulgaris
L73.2 Hydradenitis* (primary encounter diagnosis)
Had been closed at the top and packed from below, but packing fell out and became supperative
Seton made from sterile glove placed and tract re-opened sharply
Plan : **PLACEMENT, SETON
********** *STOP Clindamycin
************Start doxycycline 100mg BID for prevention of future hydradenitis flairs
************Other options to consider in the future, may be candidate for metformin
************Counseled per patient instructions

Medical Billing and Coding | AAPC Forum