Wiki Attempted Insertion Of Port-A-Cath

bonnies1103

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The surgeon tried several times to insert the Port-A-Cath and he encountered air on 2 attempts. He had x-rays taken and found the patient had bilateral pneumothorax and admitted her to Obs. The next day he inserted a chest tube. Should I code the aborted Port-A-Cath placement with a 53 modifier? the admit to Obs? He didn't do an admit note, he just used the op report as his note???
 
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