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Provider attempted to access left subclavin vein, multiple times, but discontinued and moved to the right side. How would you code this?
DOB: 6/XX/1994
PROCEDURE DATE: /2012
PRE-OP DIAGNOSIS: Pre-Op Diagnosis Codes:
* GASTROPARESIS [536.3]
POST-OP DIAGNOSIS: same
PROCEDURE: VENOUS PORT INSERTION, RIGHT SUBCLAVIAN
ANESTHESIA: General
Surgeon(s):
XXX
XXX
SIGNIFICANT FINDINGS: suggestion of subclavian vein narrowing in left
ESTIMATED BLOOD LOSS: 10 mL(s)
SPECIMEN TAKEN:No
Consent: Informed consent was obtained after detailed discussion of the indications, planned procedure, alternatives and risks.
Description of Operation/Procedure: After induction of satisfactory general anesthesia and with the patient in Trendelenburg position, the chest was prepped and draped in sterile fashion. We excised the old left upper chest scar and attempted multiple times to access the left subclavian vein, but were unable to advance a wire. There was suggestion of stenosis or obstruction. The wound was then closed in two layers and sealed with Dermabond.
The right subclavian vein was then accessed percutaneously and a wire passed into the superior vena cava under fluoroscopic guidance. After pre-injection with Marcaine, a port-pocket was created on the right superior chest wall. A previously flushed 6.6 French low-profile Mediport fit nicely in the pocket and was secured with 2 PDS sutures. The silastic catheter was trimmed to size and advanced into the superior vena cava using an introducer and the Seldinger technique under fluoroscopic guidance. The catheter aspirated and flushed easily. The tip of the catheter rested at the cavoatrial junction and there was no evidence of hemo- or pneumothorax. The Mediport pocket incision was closed in two layers and covered with Dermabond and the catheter flushed with 100 units/mL heparin.
The patient tolerated the procedure well and was awakened in anticipation of extubation and transfer to the recovery room.
I was present throughout the case.
Electronically signed by:
I want to code:
36561
36561-53
77001-26
Provider attempted to access left subclavin vein, multiple times, but discontinued and moved to the right side. How would you code this?
DOB: 6/XX/1994
PROCEDURE DATE: /2012
PRE-OP DIAGNOSIS: Pre-Op Diagnosis Codes:
* GASTROPARESIS [536.3]
POST-OP DIAGNOSIS: same
PROCEDURE: VENOUS PORT INSERTION, RIGHT SUBCLAVIAN
ANESTHESIA: General
Surgeon(s):
XXX
XXX
SIGNIFICANT FINDINGS: suggestion of subclavian vein narrowing in left
ESTIMATED BLOOD LOSS: 10 mL(s)
SPECIMEN TAKEN:No
Consent: Informed consent was obtained after detailed discussion of the indications, planned procedure, alternatives and risks.
Description of Operation/Procedure: After induction of satisfactory general anesthesia and with the patient in Trendelenburg position, the chest was prepped and draped in sterile fashion. We excised the old left upper chest scar and attempted multiple times to access the left subclavian vein, but were unable to advance a wire. There was suggestion of stenosis or obstruction. The wound was then closed in two layers and sealed with Dermabond.
The right subclavian vein was then accessed percutaneously and a wire passed into the superior vena cava under fluoroscopic guidance. After pre-injection with Marcaine, a port-pocket was created on the right superior chest wall. A previously flushed 6.6 French low-profile Mediport fit nicely in the pocket and was secured with 2 PDS sutures. The silastic catheter was trimmed to size and advanced into the superior vena cava using an introducer and the Seldinger technique under fluoroscopic guidance. The catheter aspirated and flushed easily. The tip of the catheter rested at the cavoatrial junction and there was no evidence of hemo- or pneumothorax. The Mediport pocket incision was closed in two layers and covered with Dermabond and the catheter flushed with 100 units/mL heparin.
The patient tolerated the procedure well and was awakened in anticipation of extubation and transfer to the recovery room.
I was present throughout the case.
Electronically signed by:
I want to code:
36561
36561-53
77001-26