ctown
Contributor
I have this op note that I'm stuck on. I'm trying to determine the correct anesthesia code to bill. I'm not sure what the surgeon will end up billing (49422??) but in the meantime, I'm just stuck on where to go with this one. They took this patient to the OR planning on "opening them up", however they never even made an incision. The catheter has been placed from a previous operative session (not this one) The surgeon wants to bill 00790 (wrong area- not lower but upper since umbilical area). I thought about 00400 but the skin was not even incised. Then there is the 00700 (right area-umbilical) but once again they never entered the body. Can't use a 52 modifier with anesthesia (52 not allowed on time based codes) and the patient was under so I cannot see an E&M in this. The closest would be 00400, but even that is a stretch. Any thoughts are greatly appreciated.
Here is the note:
Diagnosis: Malfunctioning peritoneal dialysis catheter
Operation Performed: Removal of peritoneal catheter
Anesthesia: IV general
Operative Prcoedure in detail:
The patient was taken to the operating room, placed supine. She had a peritoneal dialysis catheter, which had been placed in the left mid abdomen from the umbilical incision. With traction, I was able to find the cuff and then I used a hemostat, freed this up and then with gentle traction, I was able to actually remove the catheter without having to make an incision. I removed the entire catheter and then injected with local and then placed a sterile dry dressing. The patient tolerated the procedure well.
Specimens Submitted: Peritoneal dialysis catheter
Here is the note:
Diagnosis: Malfunctioning peritoneal dialysis catheter
Operation Performed: Removal of peritoneal catheter
Anesthesia: IV general
Operative Prcoedure in detail:
The patient was taken to the operating room, placed supine. She had a peritoneal dialysis catheter, which had been placed in the left mid abdomen from the umbilical incision. With traction, I was able to find the cuff and then I used a hemostat, freed this up and then with gentle traction, I was able to actually remove the catheter without having to make an incision. I removed the entire catheter and then injected with local and then placed a sterile dry dressing. The patient tolerated the procedure well.
Specimens Submitted: Peritoneal dialysis catheter