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Would you bill 49407 or 10160,76942? THANKS!
Ultrasound and fluoroscopic-guided transvaginal pelvic aspiration
History: Status post hysterectomy and bilateral salpingo-oophorectomy. Most recent surgery about 6 weeks ago. Pelvic fluid collection with pain. Low-grade fever.
Technique: Timeout performed. Patient placed in left lateral decubitus position on the fluoroscopy table. Transvaginal probe was placed and under ultrasound guidance, ill-defined mobile fluid collection was identified; 2% lidocaine used as local anesthetic. Moderate sedation also administered. Under combination of ultrasound and fluoroscopy, 5-French ring biliary catheter advanced into the fluid collection and 3 cc of purulent material aspirated. Catheter was removed. No complications occurred.
Findings: There is a complex poorly defined, compressible and mobile fluid collection in the pelvis, demonstrated with the patient in the left lateral decubitus position. A discrete abscess is not demonstrated. Purulent material was aspirated. The collection was not clearly defined or amenable to drainage due to its size and mobility. Fluid analysis is pending.
Result Impression
Successful and uncomplicated transvaginal pelvic aspiration.
Ultrasound and fluoroscopic-guided transvaginal pelvic aspiration
History: Status post hysterectomy and bilateral salpingo-oophorectomy. Most recent surgery about 6 weeks ago. Pelvic fluid collection with pain. Low-grade fever.
Technique: Timeout performed. Patient placed in left lateral decubitus position on the fluoroscopy table. Transvaginal probe was placed and under ultrasound guidance, ill-defined mobile fluid collection was identified; 2% lidocaine used as local anesthetic. Moderate sedation also administered. Under combination of ultrasound and fluoroscopy, 5-French ring biliary catheter advanced into the fluid collection and 3 cc of purulent material aspirated. Catheter was removed. No complications occurred.
Findings: There is a complex poorly defined, compressible and mobile fluid collection in the pelvis, demonstrated with the patient in the left lateral decubitus position. A discrete abscess is not demonstrated. Purulent material was aspirated. The collection was not clearly defined or amenable to drainage due to its size and mobility. Fluid analysis is pending.
Result Impression
Successful and uncomplicated transvaginal pelvic aspiration.