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Tag Archives: Please

New coder please help

Posted on by
Postoperative Diagnosis:*
1. Non-small cell lung cancer (right lower & middle lobe) s/p resection

Procedure:
1. Right thoracotomy
2. Removal of chest wall and diaphragm mesh
3. Open window thoracostomy (Claggett Procedure)

Indications:
53 y/o woman with NSCLC of the right middle and lower lobe. She underwent right bilobectomy with en-bloc chest wall & diaphragm resection &reconstruction several weeks ago and developed fever and leukocytosis. She underwent laparoscopic drainage of a perihepatic fluid collection, cultures of which failed to produce any growth. A PET CT revealed moderate uptake in the region of her chest wall mesh. For these reasons she was consented and brought to the operating room for the aforementioned procedures.
*
Anesthesia:
General
*
Estimated Blood Loss:
100*mL
*
Wound Classification:
Dirty / Infected.
*
Findings:
No purulence in the chest wall. Deep to the chest wall mesh, there was approximately 300mL of cloudy fluid drained. There was evidence of frank pus and exudate on the undersurface of the chest wall mesh. The right upper lobe was trapped and did not expand into the resultant space. Deep to the diaphragm mesh, in the retroperitoneal sulcus, there was a separate fluid collection of fran, pus that was drained. An open window thoracostomy proceeded with marsupialization of the resultant skin edges and serratus to the pleura.
*
Specimens:
1. Right pleural fluid for culture
2. Right chest wall mesh for culture
3. Retroperitoneal fluid for culture
4. Diaphragm mesh for culture
*
Procedure Details:*
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. The patient was intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the left lateral decubitus position with their right side up. The right chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, the previous extended posterior lateral skin incision was reopened with a scalpel. Dissection was carried down through subcutaneous tissues with electrocautery. Flaps were elevated above and below the latissimus muscle & serratus anterior, sparring them both. The musculature was retracted. Lung isolation was verified with anesthesia. The chest wall mesh was identified and incised sharply at its mid portion. There was cloudy effluent present in the pleural cavity with evidence of pus and fibrinous exudate along the undersurface of the chest wall mesh. This fluid was sent for culture. The chest wall mesh was explanted in its entirety. The resultant space was copiously irrigated. The right upper lobe was not expanding into the resultant space.
*
Next, the decision was made to remove the diaphragm mesh as well due to concern for contamination. The diaphragm mesh was removed in its entirety. There was a pocket of frank pus in the retroperitoneal area of the reconstruction. This was sent for culture as well. The dome of the liver was fused to the diaphragm edge. Given concern for reconstructing the resultant chest wall and diaphragm defects would lead to a space and further contamination, the decision was made to perform an open window Claggett procedure.
*
The right chest was then copiously irrigated with warm antibiotic irrigation and suctioned until clear. The thoracotomy incision was closed in layers of 2-0 and 3-0 Vicryl up to the level of the chest wall defect. The edge of the latissimus and serratus were marsupialized to the parietal pleural laterally and visceral pleura medially respectively. The skin edges were then sewn to the pleura with interrupted 0 PDS. Hemostasis was verified. The space was then packed with 2 rolls of Kerlix dressing tied together and soaked in a 1:1 solution of betadine and saline. A sterile dry ressing of 4×4 gauze was applied over this and secured.
*
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the cardiovascular recovery unit in stable condition having tolerated the procedure well. I was present, scrubbed and active during the entirety of the procedure.
*
Complications:
None.
*
Drains:
None.
*
Implants:
None.
*
Blood Products:
None.

Medical Billing and Coding Forum

New to coding this speciality please help

Posted on by
Postoperative Diagnosis:*
Empyema, Left
*
Procedure:
1. Video thoracoscopy converted to mini-thoracotomy, Left
2. Left lower lobe lung biopsy
3. Partial decortication, Left

*
Indications:
68 y/o gentleman who presented to hospital with general malaise and leukocytosis. A CT Chest was concerning for left empyema, as well as multiple lung nodules and lymphadenopathy. For these reasons, he was consented and brought to the operating room for the aforementioned procedures.
*
Anesthesia:
General
*
Estimated Blood Loss:
150*mL
*
Wound Classification:
Dirty / Infected
*
Findings:
Significant pleural thickening, pleural and lung based nodularity with partial fibrothorax of the left lower lobe. Approximately 300ml and white, cloudy effluent was drained upon initial pleural entry. Multiple pleural and lung biopsies were taken. Fluid was sent for culture and cytology.
*
Specimens:
1. Left pleural fluid for culture
2. Left pleural fluid for cytology
3. Left pleural biopsy
4. Left lower lobe, lung biopsy
*
Procedure Details:*
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with a dual-lumen endotracheal tube was affected by the anesthesia team. The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, an approximately 1cm skin incision was made overlying the 8th interspace lateral to the anterior axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. Cloudy effluent was evident upon pleural entry, some of which was sent off the field in a Luekens’ trap for culture. 2 additional working incisions were placed, one overlying the auscultory triangle and one overlying the 6th interspace and one in the 9th interspace anteriorly. The lower lobe of the lung was significantly adhered to the diaphragm and chest wall in several areas. In these areas, the parietal pleura was thickened up to 1cm, and there was significant pleural and lung based nodularity. Several areas of which were taken for biopsy using biopsy forceps. In order to attempt a decortication, the decision was made to extend our original incision to a mini thoracotomy.
*
Next, the initial incision was extended with a 10-blade scalpel. Dissection was carried down through the subcutaneous tissues with electrocautery. A small portion of latissimus was divided. The intercostal muscle overlying the 9th rib was divided and retractor inserted. The lower lobe was bluntly dissected free from the chest wall. There was thick, almost early fibrothorax present overlying most of the lower lobe. On the superior segment of the lower lobe nodularity was present. This area was biopsied sharply the the thickness of tissue was unable to accommodate a linear cutting stapler. Hemostasis was obtained. The upper lobe was lightly fused to the chest was and pericardium. The pericardial surface was left in place, while the apex and posterior surfaces were freed using blunt dissection. Several small pleural rents were made during this process.
*
Next, two 36Fr chest tubes were placed under direct vision. An anterior tube was directed towards the apex, while a posterior/inferior curved tube was placed along the diaphragm. The left upper lobe was reexpanded under direct vision. Number 2 Vicryl paracostal sutures were placed to close the interspace. All skin incisions were closed in layers with 0 and 2-0 Vicryl. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well. I was present, scrubbed and active throughout the entirety of the procedure.

Medical Billing and Coding Forum

new to coding any any help please

Posted on by
Procedure(s):
LEFT GROIN EXPLORATION REMOVAL OF INFECTED GRAFT, WOUND VAC PLACEMENT
*
Procedure Date: 2/4/2019
*
Procedure list in detail:
1. Exploration of left femoral vessels with control of hemorrhage and evacuation of hematoma
2. Excision of infected left iliofemoral and portion of left femoral-popliteal grafts
3. Wound debridement and partial wound closure with placement of wound VAC
*
Pre-operative Diagnosis: * No Diagnosis Codes entered *
*
Post-operative Diagnosis: * No Diagnosis Codes entered *
*
Indications:
Acute hemorrhage with infected graft

Anesthesia Type: General
*
Findings:
Additional graft from artery separation with clinically infected unincorporated graft and probably infected native artery
*
Procedure Details:
This is an unfortunate patient with metastatic lung cancer and severe peripheral arterial disease who has had complications related to iliofemoral graft thrombosis, infected lymphocele and subsequent graft disruption presumably from an infection. She had a minor graft separation a couple days ago which was repaired with biologic pledgets.
*
She had done recently well for a couple days but developed brisk hemorrhage from the wound again today associated with hypotension and she was brought immediately to the operating room for exploration.
*
Exploration demonstrated further separation of the patient’s graft from her native disease femoral artery around the previous site of repair. Clinically the graft is infected and likely accounts for further deterioration of the previous repairs as the area showed no significant healing from her surgery over a month ago.
*
Hemorrhage was rapidly controlled by placing a clamp on the iliofemoral portion of the graft. The graft following clamping rapidly thrombosed which at this point was okay because we did not intend to attempt further revascularization in this area. The graft was ligated above the inguinal ligament and allowed to retract into the retroperitoneum at this point. Graft was then completely removed from the femoral artery from which there was no backbleeding noted. Distal portion of the graft which consisted of a composite femoropopliteal graft was removed down to the mid thigh. Wound was irrigated and hemostasis ensured. The prior rotation flap was returned to its native donor position and the remainder of the wound left open for wound VAC application.

would 35903 be correct?

Medical Billing and Coding Forum

HELP PLEASE emergency replacement of the ascending aorta

Posted on by
Postoperative diagnosis:
#1 acute Stanford type A ascending aortic dissection with aneurysm
*
procedure:
#1 emergency replacement of the ascending aorta with hemi-arch using a 34 mm Dacron graft
#2 emergency CABG ×1 with vein graft to the LAD secondary to acute coronary dissection
#3 extensive lysis of pericardial adhesions
#4 right axillary artery cutdown with placement of 8 mm end-to-side Dacron graft for cannulation
#5 ultrasound-guided percutaneous right femoral venous cannulation
#6 placement of left femoral arterial line
#7 cardiopulmonary bypass
#8 deep hypothermic circulatory arrest, 18°C
#9 Cerebral Somanetics monitoring
#10 reinstitution of cardiopulmonary bypass
#11 complex management of coagulopathy, 2 hours
#12 open saphenous vein harvest, left lower extremity, 1 vein segment
#13 TEE with visualization and interpretation ×2
#14 epi-aortic ultrasound with visualization and interpretation

*
Indication:
77-year-old female presenting with acute onset of chest pain radiating to the back. She was evaluated at M B campus in which a CT, PE protocol was performed which revealed an ascending aortic dissection. She was transferred to Center for further care. She’s been taken to the operating suite for emergency repair of ascending aorta.
*
Intraoperative findings:
Pre-bypass TEE showed normal left ventricular function. There was mild concentric left ventricular hypertrophy. There were no regional wall motion abnormalities. Right ventricular function was normal. There was trace to mild mitral regurgitation. The left atrial appendage was free of thrombus. The aortic valve leaflets were coapting appropriately, with no evidence of dilation of the aortic root. There was mild to moderate central aortic insufficiency noted his own of coaptation centrally. The sinotubular junctions were thickened, but not effaced. The aortic dissection could be identified with thrombosis within the false lumen.
*
Initial TEE upon weaning from cardiopulmonary bypass showed preservation of the ventricular function. However, within a few minutes of weaning from bypass, the patient began having hemodynamic instability. The heart was becoming arrhythmia genic. Reevaluation of the TEE revealed that there was severe hypokinesis/akinesis of the anterior wall. This finding prompted the decision to re-heparinize and go emergently back on cardiopulmonary bypass.
*
Once on bypass, epi-aortic ultrasound was actually used to evaluate the LAD territory. At the most proximal portion of the LAD, a dissection flap was identified which explains the severe hypokinesis of the anterior wall. Emergency bypass grafting to the LAD territory was performed using vein graft to the left leg. Once this was completed, final TEE was performed which showed normal ventricular function upon immediate weaning, no alteration in native valvular function. The aortic root was well visualized with no alterations in the native aortic valve function.
*
Upon entering the pericardium, it was evident the patient had a combination of subacute and chronic pericarditis. Exact etiology is unknown. There is no purulent fluid. Extensive lysis of pericardial adhesions had to be performed in order to achieve the operation. Femoral venous cannulation was performed because central venous cannulation could not be performed secondary to the severe displacement of the right atrium relative to the IVC because of the ascending aortic aneurysm. The aneurysm itself was over 6 cm in size. It is incredibly thin walled. The intimal tear was identified on the lesser curvature of the distal ascending aorta. This area was completely resected during the repair. There was no evidence of intimal tear within the aortic arch.
*
Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines and been placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision.
*
A right subclavicular incision was made with a 10 blade scalpel. Soft tissues were divided. The pectoralis muscle was released from its clavicular attachments. The underlying soft tissues were divided to expose the right axillary artery. Great care was taken to preserve the brachial plexus. Right axillary artery was then encircled with Vesseloops proximally and distally for hemostatic control. The patient was given 6000 units of heparin and vascular clamps were placed. A longitudinal arteriotomy was made with a 15 blade scalpel and extended. An 8 mm Dacron graft was then anastomosed to the right axillary artery using 5-0 Prolene. The graft was then de-aired. It was connected to the arterial line for arterial cannulation and bypass.
*
Pre-bypass TEE had been performed by this point in time. Findings are as dictated above.
Sternal incision was made. Soft tissues were identified. Sternotomy was performed in the standard fashion. Sternal retractor was placed. The anterior mediastinal soft tissues were divided. The innominate vein was completely collapsed secondary to the size of the aneurysm placed in the vein on stretch. The pericardium was then opened in which there was extensive pericardial adhesions, some of which were subacute and other show evidence of chronicity. Stay sutures then placed create a pericardial well. Great care was taken to minimize any manipulation the ascending aorta, as it was evident that the wall was extremely thin.
*
The patient was fully heparinized. ACT was found be therapeutic for bypass. Central venous cannulation was attempted multiple times, but the severe angle created by the displacement of the atrium by the aneurysm made routine central cannulation difficult. Decision was then made to perform right femoral venous cannulation. The ultrasound was used to identify the right femoral vein. The vein was compressed and showed no evidence of DVT. Under real-time ultrasound, single anterior wall puncture was performed and the guidewire was placed and confirmed to be across the IVC and SVC under TEE guidance. Serial dilation over wire was performed and the femoral venous cannulation was placed and confirmed in position by TEE. The patient was then placed on full cardiopulmonary bypass and systemically cooled to 18°C.
*
A total of 90 minutes was dedicated purely to lysis of adhesions. This included off-pump lysis of adhesions as well as lysis of adhesions on the patient was on bypass.
*
The innominate artery could not easily be accessed in order to perform selective antegrade cerebral perfusion. Secondary to this, decision made to perform deep hypothermic circulatory arrest. The patient was cooled to 18°C for at least 20 minutes. Once this was completed, the deep hypothermic circulatory arrest was instituted. The bypass pump was turned off. The aorta was opened which revealed a large aneurysm with acute thrombus within the false lumen. The left main coronary artery was evaluated and noted cardioplegia to the left main as well as right coronary ostia was given to achieve complete diastolic cardiac arrest. Left main appeared to be uninvolved in the dissection. The dissection extended to just above the right coronary ostia. This ostomy later be secured with pledgeted 5-0 Prolene sutures.
*
The ascending aorta was then resected with accommodation of Metzenbaum scissors as well as cautery. It was taken to the level of the innominate takeoff and a hemi-arch configuration was constructed. The intimal tear was resected during this portion of the procedure. Using a felt sandwich technique, a felt strip was tacked intraluminally as well as extraluminally and secured with 5-0 Prolene. It was sized to a 34 mm graft. The graft was then anastomosed to the proximal aortic arch using 3-0 Prolene in a running fashion. BioGlue was placed over the anastomosis. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After the graft was adequately de-aired, cross-clamp was placed in full antegrade perfusion was reinstituted and the patient was warmed to 32°C.
*
The remainder of the ascending aorta was resected to the level of the sinotubular junction. As stated above, the right coronary artery was widely patent, but the dissection didn’t extend to just above the right coronary artery. The right coronary ostia was slightly higher than the initial attachments. This was secured with pledgeted 5-0 Prolene suture. Once this was completed, a double felt sandwich technique was used to find the proximal anastomosis in a similar fashion as previously described. The patient had been systemically rewarmed. The needle vent was placed and de-airing maneuvers were then performed. Once this was completed, the cross-clamp was removed and the heart was allowed to be reperfused.
*
The heart regained spontaneous rhythm. Pacing wires placed on the right ventricle brought out to the level of the skin. Lungs were ventilated. Anastomoses were found to be hemostatic. The heart was then weaned from bypass without difficulty. Protamine had initially been started and venous cannula was removed. Shortly after this, the patient began having hemodynamic issues with hypotension and the heart was with the genetic. TEE was then used to evaluate the heart. During the TEE evaluation, the left ventricular function was severely depressed and there was severe anterior wall hypokinesis. She was initially treated medically with significant improvement, but quickly deteriorated into the similar situation previously described. Decision was made to re-heparinize and reinstituted cardiopulmonary bypass.
*
Decision was made to bypass the LAD. The LAD was identified and isolated. The vein graft had been harvested from the left lower extremity using an open incision technique by . After was prepped, bleeding heart pump-assisted bypass to the LAD was performed. Arteriotomy was made and extended. The vein grafts beveled and spatulated. It was anastomosed using 7-0 Prolene. The proximal anastomosis was then placed on the ascending aortic graft using a side-biting clamp to achieve hemostasis while creating the anastomosis. The vein graft was de-aired after the clamp was removed.
*
Lungs were ventilated. Pacing wires were placed on the right ventricle. The heart was then weaned from bypass without difficulty. The TEE was reevaluated which showed significant improvement in the anterior wall function with adequate de-airing of the left ventricle. Left ventricular function was found to be normal. Decision was made to give protamine to reverse the effects of heparin. The femoral venous cannula was removed and pressure was held to assist with hemostasis.
*
The next 2 hours were spent administering blood products which include packed red cells, FFP, platelets, cryo-, factor VII in order to achieve hemostasis. As the patient required more and more volume, the hemodynamics were marginal at best. She is being supported by epinephrine drip, milrinone, vasopressin, as well as several doses of bicarbonate for the management of metabolic acidosis, calcium chloride. Once hemostasis was achieved, decision was made to close the chest. The sternum was reapproximated with #7 wires. Prior to closure, a right angle chest tube as well as a 32 French straight mediastinal chest tube were placed in the mediastinum. The superior abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl in a running subcuticular manner.
*
Throughout the procedure, the patient was being monitored with cerebral Somanetics. Her initial readings ranged between 40 and 60th percentile. During hypothermic circulatory arrest, readings ranged from 30-45 percentile. She had lower numbers after weaning from bypass, largely related to severe anemia which was being treated with transfusions.
*
Also, during her hemodynamics instability, the left radial arterial line was transducing, but could not be drawn back. Decision was made to place a left femoral arterial line. A percutaneous access left femoral artery and placed the wire. Small stab incision was made. Dilator was placed over wire and a Seldinger technique. The femoral arterial line was placed and secured with 2-0 silk.
*
The right axillary Dacron graft was clipped proximally and then oversewn with 5-0 Prolene. The excess graft was excised and the deep soft tissues were closed with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Dermabond was placed over the wounds. The patient was then transferred to CVRU in critical condition.

33860 22
33510 51
33508
76998 26 59
93314 26

ARE THESE CORRECT?

Medical Billing and Coding Forum

new to coding any help please

Posted on by
postoperative diagnosis:
#1 anterior pericardial cyst
#2 atypical chest discomfort
*
procedure:
#1 right robotic-assisted thoracoscopic resection of anterior pericardial cyst

39200 22 for robotic ?
*
Intraoperative findings:
Large pericardial cyst herniating laterally into the right pleural space. Origin of the cyst was along the distal greater curvature of the aorta. No inflammatory findings identified. Pericardial fluid was serous in nature. Full resection was performed with a 1 x 1.5 cm defect left in the pericardial sac near the distal greater curvature of the aorta.
*
Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines were placed by anesthesia. The patient was wrapped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision.
*
Small 8 mm incision was made at roughly the fifth intercostal space, mid axillary line on the right. Soft tissues were divided with cautery. The introducer needle was then inserted into the right pleural space and the right pleural space was insufflated with CO2 to a pressure of 4 mmHg. The camera port was then placed. Once this was completed, an 8 mm port was placed inferiorly at approximately the eighth intercostal space, anterior axillary line. A superior port was placed near the right axilla. This was all performed under direct visualization.
*
The da Vinci SI system was then docked in the usual fashion. Once this was completed, caudier graspers were inserted. Gross inspection of the pericardial cyst was performed. Using bipolar as well as monopolar dissection, the pericardial fat and thymic tissue were released from the pericardial cyst and the neck was identified at the along the greater curvature of the aorta. The pericardial cyst was then opened with monopolar cautery. Serous fluid was drained which allowed for excellent visualization of the neck and the cyst. The cyst was then completely removed and submitted for permanent specimen. A 1 x 1.5 cm defect was left in the pericardium at the most distal aspect of the ascending aorta.
*
A 24 French Silastic chest tube was then placed anteriorly and positioned near the working site. Ports were removed under direct visualization and found to hemostatic. Camera was removed and all incision sites were closed in layers, with 2-0 Vicryl being used to close the soft tissues. Skin was closed with 4 Monocryl running subcuticular manner. The soft tissues had been injected with half percent Marcaine for local anesthesia. The patient tolerated the procedure well, was extubated, then transferred recovery.
*

Medical Billing and Coding Forum

Coil Embolization and Two Iliac balloons – Please help!

Posted on by
Any help is much appreciated. I came up with the following:

37220-78-RT
+37222-RT
37244-80-RT

PROCEDURES PERFORMED:
1. Right lower extremity angiography.
2. Balloon inflation of the right external iliac artery with an Armada 4 mm x 40 mm balloon, balloon inflation of the right common iliac artery with an Armada 7 mm x 40 mm balloon, coiling of the right inferior epigastric artery with Interlock 2×3 mm, 2×4 mm and 3×6 mm coils.

INDICATIONS FOR PROCEDURE: Patient is a 34-year-old Caucasian female that presented earlier today for an outpatient atrial septal defect closure via right and left femoral venous access. Post procedure, she had a right groin hematoma and complained of extensive pain. She was hypotensive and continued to be unstable, so the patient was brought back to the Cath Lab emergently for lower extremity angiography.

FLUOROSCOPY TIME: 17.5 minutes.

RADIATION EXPOSURE: 578 milligray.

CONTRAST: 100 mL of Omnipaque.

PROCEDURE IN DETAIL: The patient was brought to the Cardiac Cath Lab in an emergent fashion. The bilateral groins were prepped and draped in the usual sterile fashion. The skin overlying the left common femoral artery was anesthetized with 1% lidocaine. A Cook needle was used to access the left common femoral artery under direct ultrasound visual guidance and a 6-French short sheath was placed. At that time, a Contra catheter was advanced over a J-tipped wire and used to engage the right common iliac artery. The J-tipped wire was then advanced down into the right common femoral artery. The Contra catheter was removed and a 4-French Glidecath was advanced over the wire into the right external iliac artery. At that time, selective right lower extremity angiography was performed with hand injection of contrast. We noted that there was extensive extravasation of contrast from the inferior epigastric artery on the right. The Glidecath was removed over a wire and then the 6F short sheath was exchanged out for a 6F Destination sheath which was placed in the right common iliac artery. An Armada 4 mm x 40 mm balloon was advanced over the J-tipped wire into the proximal portion of the right external iliac artery. That balloon was inflated to 2 atmospheres for 5 minutes. We then performed another angiogram and noted that there was still extravasation, so it was inflated for another 5 minutes. We then performed another angiogram and noted that there was extravasation from the same vessel from branches coming from the internal iliac artery as well, so that balloon was removed and an Armada 7 mm x 40 mm balloon was placed in the distal right common iliac artery just proximal to the bifurcation. Balloon occlusion was performed for 10 minutes and we repeated angiography and noted that there was still extravasation. Another balloon inflation was performed at 6 atmospheres for 10 minutes and we were still unable to control the bleeding despite already giving protamine and having multiple balloon inflations.

At that time, I asked Dr. _______ for assistance and he joined the procedure to help with coil embolization of the bleeding artery. The balloon was removed and a 6-French IMA guide catheter was advanced through the 6-French Destination sheath. The IMA guide was directed towards the ostium of the inferior epigastric artery and then a BMW wire was advanced up the inferior epigastric artery. We then placed a microcatheter over the BMW guidewire up into the inferior epigastric artery and removed the BMW wire. At that point, we were able to deploy 2 coils in the more superior aspect of the inferior epigastric artery, distal to where the bleeding was noted, and then pulled the microcatheter down and place 1 more coil proximal to the bleeding site in the inferior epigastric artery. A repeat angiogram was performed and we noted that we had achieved hemostasis of the inferior epigastric artery with the coils. The microcatheter was removed and the multipurpose guide catheter was removed. We again repeated right lower extremity angiography through the Destination sheath and noted that the common iliac, internal iliac, external iliac, femoral, and profunda arteries were all patent, although severely vasospastic, and there was no longer any signs of extravasation from the inferior epigastric artery. At that time, the Destination sheath was removed from the left groin over a wire and a 6 French short sheath was placed. An angiogram was performed noting that the left femoral artery was acceptable for a closure device. The 6-French Angio-Seal was deployed successfully.

FINDINGS:
1. Right lower extremity angiography.
2. Severe vasospasm in all the lower extremity arteries.
3. Widely patent right common iliac, right external iliac, and right internal iliac arteries.
4. Extravasation of contrast from the right inferior epigastric artery near the takeoff from the common femoral artery.
5. Post procedure there was no longer any extravasation noted from the inferior epigastric artery.

ASSESSMENT AND PLAN:
1. Extravasation of contrast from the right inferior epigastric artery.
2. Successful coiling of the right inferior epigastric artery with 3 Interlock coils both proximal and distal to the site of extravasation.
3. We will admit the patient to the CCU and monitor closely. The patient received 2 units of PRBCs during the procedure. We will wean the phenylephrine drip off as soon as possible.

I administered moderate sedation throughout this 118-minute procedure. An independent trained observer pushed medication at my direction and monitored the patient’s level of consciousness and physiologic status throughout.

Medical Billing and Coding Forum

Help with Breast Excision Op Note Please

Posted on by
Can anyone give any guidance for this. Thinking 19281 or 19125 or both??

Indications: This patient has a papilloma and mass of the of the right breast which was previously biopsied and requires excision.

Pre-operative Diagnosis: right breast mass and papilloma
*
Post-operative Diagnosis: right breast mass and papilloma
*
*
*
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, bleeding, infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was taken to operating room identified correctly and the procedure verified as right Needle localized Breast mass Excision. A Time Out was held and the above information confirmed.
*
The patient was placed prone on the stereotactic core table. The right breast clip lesion was localized stereotactically. Using standard aseptic technique and 1% Lidocaine and for local anesthetic. A 9cm Kopans needle wire device was then advanced ot the targeting coordinates. Stereotactic imaging was used to confirm appropriate localization. The wire was deployed and imaging confirmed appropriate wire placement. Sterile dressing was placed with steristrips and gauze. The patient tolerated this procedure well without complications. She was then brought to the OR.
The patient was placed supine. The breast was prepped and draped in the standard fashion. Lidocaine 0.5% with epinephrine and bicarbonate was used to anesthetize the skin over the external portion of the wire.

An curvilinear incision was created at 8-10:00 in the periareolar skin near the external wire. Dissection was carried down through the subcutaneous fat. A core of breast tissue was taken around the wire and excised. The specimen was then imaged and the clip was confirmed to be in the tissue. Hemostasis was achieved with cautery. Closure was performed in 2 layers with a 4-0 monocrylsubcuticular closure. The specimen was oriented with sutures- short superior,long lateral.
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Steri-Strips were applied. At the end of the operation all sponge, instrument and needle counts were correct. interpreted all images during the procedure.
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Medical Billing and Coding Forum

Please Help with Op Report Vacular coding

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Anyone one willing to take a look and help me out please.
I’m thinking 36222-50 and 75650

PROCEDURE:
1. Percutaneous right common femoral artery access with ultrasound guidance.
2. Cannulation of aortic arch.
3. Arteriogram of aortic arch.
4. Selective cannulation of right common carotid artery.
5. Angiogram of right common carotid artery.
6. Selective cannulation of left common carotid artery.
7. Angiogram of left common carotid artery.
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DESCRIPTION OF PROCEDURE:
Patient was taken to the angiography suite and placed in a supine position. Mild sedation was given and the groins were prepped and draped in a sterile manner. 1% lidocaine was used to infiltrate the surgical area. Percutaneously, the right common femoral artery was accessed under direct ultrasound guidance. A guidewire was inserted under fluoroscopy. Over the guidewire, a 5-French introducer was placed. Over the guidewire into the introducer a 5-French pigtail catheter was inserted and guided to the proximal aortic arch. An angiogram was performed of the arch. Once angiogram was performed, the pigtail catheter was removed and was exchanged to a Vitek catheter over a Glidewire. Selectively the right common carotid artery was accessed and the catheter was advanced into the right common carotid artery. From this position an angiogram of the right carotid artery was done. The guidewire was reinserted and the catheter was backed out into the arch and selective cannulation of the left common carotid artery was performed and the catheter was advanced into the left common carotid artery. From this position an angiogram was performed of the left system. During the angiogram of the left and the right common carotid arteries, multiple views were taken including oblique view and AP and lateral views. The catheter was then removed and the introducer was removed. Hemostasis was obtained by direct pressure for 20 minutes. Dressings were placed and the patient was then transferred to the recovery room stable. No complication was seen. The estimated blood loss was minimal.
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FINDINGS:
The patient was seen to have a normal aortic arch with the great vessels. There were no abnormalities and stenosis.
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On the right side, the common carotid artery was widely patent along with the external carotid artery. The internal carotid artery shows atherosclerotic changes at its origin and after reviewing several views there is no hemodynamically significant narrowing.
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On the left side, the common carotid artery is widely patent. The internal carotid artery itself shows mild disease with narrowing of approximately 15-20%. The external carotid artery, however, has a high-grade stenosis of greater than 90%, short segment at its origin.
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At this time, the patient will follow up in the office for further consultation and discussion of the findings as well as future management plans.
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Medical Billing and Coding Forum