bda23054
Networker
Would greatly appreciate insight on coding this procedure:
POSTOPERATIVE DIAGNOSIS
Peri nephrotic abscess left side.
NAME OF PROCEDURE
CT-guided pigtail placement and drainage of abscess.
ANESTHESIA
IV
INDICATIONS
This was an 80-year-old male who presented with abdominal pain, leukocytosis, who on CAT scan was noted to have a large peri nephrotic abscess suggestive of pyelonephritis and rupture of the collecting system. So because of this I was consulted for drainage.
DESCRIPTION OF PROCEDURE
The patient was brought to the CT suite, placed in the supine position with wedge under the left side. Radiopaque marker was placed pre-procedure over the suspected abscess. Scout films were taken and did verify proper placement of the radiopaque marker which was then marked with the help of the radiopaque marker in the CT scanner itself. The area was then prepped and draped in the usual sterile fashion. 1% Lidocaine was injected in the skin and subcutaneous tissues. The anesthetic needle was left behind and another scout film was taken showing again proper trajectory. Nick incision was made and using an 8-French curved catheter, was inserted under CT guidance directly into the peritoneal cavity into the abscess. Approximately 350 mL of purulent material was removed and cultures were sent. CT scan was then performed again, showing near resolution of the abscess. The drain was left in place and using the securing device provided and a 2-0 silk suture the device was secured to his skin. It was connected to a 3-way stop cock and an air-seal bag. OpSite was placed. The patient tolerated the procedure well and was wheeled back to his room in stable room.
POSTOPERATIVE DIAGNOSIS
Peri nephrotic abscess left side.
NAME OF PROCEDURE
CT-guided pigtail placement and drainage of abscess.
ANESTHESIA
IV
INDICATIONS
This was an 80-year-old male who presented with abdominal pain, leukocytosis, who on CAT scan was noted to have a large peri nephrotic abscess suggestive of pyelonephritis and rupture of the collecting system. So because of this I was consulted for drainage.
DESCRIPTION OF PROCEDURE
The patient was brought to the CT suite, placed in the supine position with wedge under the left side. Radiopaque marker was placed pre-procedure over the suspected abscess. Scout films were taken and did verify proper placement of the radiopaque marker which was then marked with the help of the radiopaque marker in the CT scanner itself. The area was then prepped and draped in the usual sterile fashion. 1% Lidocaine was injected in the skin and subcutaneous tissues. The anesthetic needle was left behind and another scout film was taken showing again proper trajectory. Nick incision was made and using an 8-French curved catheter, was inserted under CT guidance directly into the peritoneal cavity into the abscess. Approximately 350 mL of purulent material was removed and cultures were sent. CT scan was then performed again, showing near resolution of the abscess. The drain was left in place and using the securing device provided and a 2-0 silk suture the device was secured to his skin. It was connected to a 3-way stop cock and an air-seal bag. OpSite was placed. The patient tolerated the procedure well and was wheeled back to his room in stable room.