Shirleybala
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Hi,
How to code this report,My codes are
36000
37187
93971 26
Please confirm.
78 year old male with insufficiency of the left short
saphenous vein status post successful EVLT of this vein two months
ago, status post sclerotherapy of residual varicosities within the
posterior calf 3 weeks ago returns for follow up examination.
Mr. XXX states that he feels well. He is notes some tenderness
to palpation and a "hard feeling" at the sclerotherapy injection
sites. Physical examination of the left leg and foot demonstrates
several palpable
cords posterior to the left knee. Minimal discoloration is noted
posterior to the knee. Doppler ultrasound examination of the left
lower extremity veins demonstrates continued occlusion of the
short saphenous vein within the calf. Previously sclerosed
varicosities within the calf are thrombosed.
The posterior calf was then prepped with alcohol solution. Local
anesthesia was administered to the tissue surrounding the
thrombosed varicosities. Using 18 gauge needles, aspiration of
thrombus from the varicosities was performed. A large amount of
thrombus was aspirated from the varicosities with significant
decompression of them.the catheter was wrapped with an Ace wrap.
The patient is to return for follow-up examination in two months.
How to code this report,My codes are
36000
37187
93971 26
Please confirm.
78 year old male with insufficiency of the left short
saphenous vein status post successful EVLT of this vein two months
ago, status post sclerotherapy of residual varicosities within the
posterior calf 3 weeks ago returns for follow up examination.
Mr. XXX states that he feels well. He is notes some tenderness
to palpation and a "hard feeling" at the sclerotherapy injection
sites. Physical examination of the left leg and foot demonstrates
several palpable
cords posterior to the left knee. Minimal discoloration is noted
posterior to the knee. Doppler ultrasound examination of the left
lower extremity veins demonstrates continued occlusion of the
short saphenous vein within the calf. Previously sclerosed
varicosities within the calf are thrombosed.
The posterior calf was then prepped with alcohol solution. Local
anesthesia was administered to the tissue surrounding the
thrombosed varicosities. Using 18 gauge needles, aspiration of
thrombus from the varicosities was performed. A large amount of
thrombus was aspirated from the varicosities with significant
decompression of them.the catheter was wrapped with an Ace wrap.
The patient is to return for follow-up examination in two months.