How to code the below procedure????
Clinical history: 57-year-old female who presented with perforated
acute cholecystitis status post cholecystostomy tube placement on
10/19/2009. Patient had CT scan on 10/21/2009 demonstrating a
persistent pericholecystic collection. Request is made for CT
guided aspiration.
The patient was placed supine on the CT table. Preliminary CT was
performed with a grid overlying the right upper quadrant to mark a
site for drainage. A right lateral site adjacent to the
cholecystostomy tube was marked, prepped and draped in a sterile
fashion. The area was locally anesthetized with 1% lidocaine.
Using CT guidance, a 19 gauge guiding needle was advanced,
positioned with the tip within the hepatic collection. An Amplatz
wire was advanced and seen coiled within the lesion. The tract
was dilated and an 8 Fr APD catheter was placed. The loop was
formed and locked in place. The position was verified with
another series of images. Only a few cc of bloody mucoid material
was aspirated. After consultation with Dr. Grace Kim, the
referring physician, the decision was made to remove the catheter.
After the catheter was removed, a sterile dressing was applied,
thus terminating the procedure. Specimen was taken to Pathology
at the end of the procedure for culture and sensitivity.
The patient tolerated the procedure well, and left the department
in stable condition. There were no complications
Impression: CT guided aspiration of a pericholecystic collection
with 8 Fr APD. Only a few cc bloody mucoid fluid aspirated.
Specimen was given to Vanessa at the microbiology lab.
Clinical history: 57-year-old female who presented with perforated
acute cholecystitis status post cholecystostomy tube placement on
10/19/2009. Patient had CT scan on 10/21/2009 demonstrating a
persistent pericholecystic collection. Request is made for CT
guided aspiration.
The patient was placed supine on the CT table. Preliminary CT was
performed with a grid overlying the right upper quadrant to mark a
site for drainage. A right lateral site adjacent to the
cholecystostomy tube was marked, prepped and draped in a sterile
fashion. The area was locally anesthetized with 1% lidocaine.
Using CT guidance, a 19 gauge guiding needle was advanced,
positioned with the tip within the hepatic collection. An Amplatz
wire was advanced and seen coiled within the lesion. The tract
was dilated and an 8 Fr APD catheter was placed. The loop was
formed and locked in place. The position was verified with
another series of images. Only a few cc of bloody mucoid material
was aspirated. After consultation with Dr. Grace Kim, the
referring physician, the decision was made to remove the catheter.
After the catheter was removed, a sterile dressing was applied,
thus terminating the procedure. Specimen was taken to Pathology
at the end of the procedure for culture and sensitivity.
The patient tolerated the procedure well, and left the department
in stable condition. There were no complications
Impression: CT guided aspiration of a pericholecystic collection
with 8 Fr APD. Only a few cc bloody mucoid fluid aspirated.
Specimen was given to Vanessa at the microbiology lab.
