chembree
Guru
CT GUIDED DRAIN PLACEMENT
HISTORY: Anterior bowel wall fluid collection postoperative. Status
post laparoscopic surgery.
COMPARISON: Preoperative exam 9/26/2012.
MEDICATIONS: Fentanyl and Versed were titrated to effect for moderate
sedation. Direct face to face sedation was provided under my supervision
for approximately 30 minutes.
PROCEDURE: Pre procedure CT scout images with the patient supine
demonstrate intra-abdominal wall ovoid subcutaneous fluid collection
with a small amount of gas bubbles seen midline having dimension of 12 x
6 cm. The risks, benefits, and alternatives to the procedure and
moderate sedation were explained to the patient, and informed written
consent was obtained.
The skin overlying the lesion was marked for appropriate site for entry.
The anterior abdomen was prepped and draped in the usual sterile
fashion. A procedural pause was performed and 2% lidocaine was used as
local anesthetic. A 21 gauge introducing needle was utilized and
position was confirmed with further CT imaging. Next through the needle
,an 0.18 guidewire was placed. Transitional catheter was placed over the
guidewire. A 0.035" Amplatz wire was coiled in the fluid collection.
Old thin bloody material was obtained from with some particulate clots
noted. A 10 French all purpose drainage locking catheter was advanced
over the wire with the cope loop formed in the fluid collection. Follow
up imaging to confirm position was obtained. The catheter was secured
to the skin and attached to a bulb suction, gravity drainage bag.
Hemostasis was achieved using manual compression. A sterile dressing
was applied. The patient tolerated the procedure well with no immediate
complications and was discharged from the procedure in stable condition.
Sample obtained: 120 mL of old dark red serosanguineous fluid.
IMPRESSION: Successful CT guided drain placement intra-abdominal fluid
collection.
Thank you for referring patient to Interventional Radiology for their
procedure and allowing me to participate with you in their care
How would you code this? It is my understanding that a paracentesis (49083) is an aspiration of fluid from the abominal cavity and that an aspiration involves removal of the catheter or needle at the conclusion of the procedure.
CPT 49021 describes a drainage of peritoneal abscess OR LOCALIZED PERITONITIS. Does this procedure fall under this since the collection was of the anterior bowel wall?
HISTORY: Anterior bowel wall fluid collection postoperative. Status
post laparoscopic surgery.
COMPARISON: Preoperative exam 9/26/2012.
MEDICATIONS: Fentanyl and Versed were titrated to effect for moderate
sedation. Direct face to face sedation was provided under my supervision
for approximately 30 minutes.
PROCEDURE: Pre procedure CT scout images with the patient supine
demonstrate intra-abdominal wall ovoid subcutaneous fluid collection
with a small amount of gas bubbles seen midline having dimension of 12 x
6 cm. The risks, benefits, and alternatives to the procedure and
moderate sedation were explained to the patient, and informed written
consent was obtained.
The skin overlying the lesion was marked for appropriate site for entry.
The anterior abdomen was prepped and draped in the usual sterile
fashion. A procedural pause was performed and 2% lidocaine was used as
local anesthetic. A 21 gauge introducing needle was utilized and
position was confirmed with further CT imaging. Next through the needle
,an 0.18 guidewire was placed. Transitional catheter was placed over the
guidewire. A 0.035" Amplatz wire was coiled in the fluid collection.
Old thin bloody material was obtained from with some particulate clots
noted. A 10 French all purpose drainage locking catheter was advanced
over the wire with the cope loop formed in the fluid collection. Follow
up imaging to confirm position was obtained. The catheter was secured
to the skin and attached to a bulb suction, gravity drainage bag.
Hemostasis was achieved using manual compression. A sterile dressing
was applied. The patient tolerated the procedure well with no immediate
complications and was discharged from the procedure in stable condition.
Sample obtained: 120 mL of old dark red serosanguineous fluid.
IMPRESSION: Successful CT guided drain placement intra-abdominal fluid
collection.
Thank you for referring patient to Interventional Radiology for their
procedure and allowing me to participate with you in their care
How would you code this? It is my understanding that a paracentesis (49083) is an aspiration of fluid from the abominal cavity and that an aspiration involves removal of the catheter or needle at the conclusion of the procedure.
CPT 49021 describes a drainage of peritoneal abscess OR LOCALIZED PERITONITIS. Does this procedure fall under this since the collection was of the anterior bowel wall?