This one has me stumped & I would appreciate any assistance I can get. Here are pertinent sections from the chartnote:
1) "Patient complains of a foreign body in her right hand following having an IV that malfunctioned. It has been there for several weeks and is beginning to cause more pain. The patient believes that it is an IV that was left in and she insists that I remove it." 2) "Right hand has a palpable mass that is long and thin over the dorsum of the thenar space, about 2.5cm x 1mm, it is stiff, but flexible. There is some discoloration of the skin overlying." 3) "I discussed the risks of attempting to remove a foreign body here in the clinic, and recommended to her that I refer her to a surgeon. She refused and wants me to do it here. The consent having been signed, I attempted the removal in the office. The area was prepped and draped in a sterile fashion. Anesthesia was achieved with approximately 1.5 cc of lidocaine with epinephrine. An incision of about 2cm was made over the palpable abnormality. A blunt dissection was carried out down to the vein and then it was incised. There was old blood and clot expressed. An attempt was made to find a foreign body, a section of thickened and scarred vein was removed. (I clarified this with the provider; the vein had basically dead-ended due to the clot & there was no blood flow) The wound was closed with 4.0 nylon with 3 simple interrupted sutures with good cosmesis and hemostasis. Total blood loss estimated at 1cc. It is unclear if there was a foreign body that was not found, or if the palpable abnormality was clot and scarred vein." (When patient returned for follow up, there was no evidence of a mass or foreign body)
Does anyone have suggestions on how to code this? Provider gave me M79.5 as a dx, which is what he thought before he did the procedure. Neither of us thinks it really fits. I can’t find a CPT code that really applies either. Thanks!
1) "Patient complains of a foreign body in her right hand following having an IV that malfunctioned. It has been there for several weeks and is beginning to cause more pain. The patient believes that it is an IV that was left in and she insists that I remove it." 2) "Right hand has a palpable mass that is long and thin over the dorsum of the thenar space, about 2.5cm x 1mm, it is stiff, but flexible. There is some discoloration of the skin overlying." 3) "I discussed the risks of attempting to remove a foreign body here in the clinic, and recommended to her that I refer her to a surgeon. She refused and wants me to do it here. The consent having been signed, I attempted the removal in the office. The area was prepped and draped in a sterile fashion. Anesthesia was achieved with approximately 1.5 cc of lidocaine with epinephrine. An incision of about 2cm was made over the palpable abnormality. A blunt dissection was carried out down to the vein and then it was incised. There was old blood and clot expressed. An attempt was made to find a foreign body, a section of thickened and scarred vein was removed. (I clarified this with the provider; the vein had basically dead-ended due to the clot & there was no blood flow) The wound was closed with 4.0 nylon with 3 simple interrupted sutures with good cosmesis and hemostasis. Total blood loss estimated at 1cc. It is unclear if there was a foreign body that was not found, or if the palpable abnormality was clot and scarred vein." (When patient returned for follow up, there was no evidence of a mass or foreign body)
Does anyone have suggestions on how to code this? Provider gave me M79.5 as a dx, which is what he thought before he did the procedure. Neither of us thinks it really fits. I can’t find a CPT code that really applies either. Thanks!
J. Beck, CPC