Ct guided renal cyst ablation / aspiration x 4

chembree

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CT GUIDED RENAL CYST ABLATION / ASPIRATION X 4

HISTORY: Bilateral symptomatic large renal cyst 2 right kidney, 2 left
kidney.

COMPARISON: None

MEDICATIONS: Fentanyl and Versed were titrated to effect for moderate
sedation. Direct face to face sedation was provided under my supervision
for approximately 45 minutes.

PROCEDURE:The risks, benefits, and alternatives to the procedure and
moderate sedation were explained to the patient, and informed written
consent was obtained.

Pre procedure CT scout images with the patient in the prone position
demonstrates bilateral large cyst. There are 2 large cyst left kidney
upper pole up to 7.2 cm in dimension and lower pole of two 6.1 cm in
dimension. There are 2 large right renal cyst upper pole 5.5 cm and
lower pole smaller 3.6 cm.

The skin overlying the lesions were marked for appropriate site for
entry. The back was prepped and draped in the usual sterile fashion. A
procedural pause was performed and 2% lidocaine was used as local
anesthetic. A 5 French pigtail UV catheters were utilized at the 4
sites into the fourth cyst. 20 mL of thin yellow fluid was obtained from
all 4 of the cyst and sent to laboratory for cytology examinations with
each syringe marked appropriately. Next 80 additional mL were withdrawn
from the upper pole left renal cyst and 80 mL from the upper pole and
the lower pole right renal cysts were removed.

Following this 10 mL dehydrated absolute alcohol was then slowly
delivered into each of these cysts though the left lower pole cyst the
if needed only 5 mL given its small size. The alcohol was left in place
for a total of 10 minutes. After 10 minutes an additional 45 mL of fluid
was removed from the upper pole right renal cysts and 23 mL additional
fluid removed from the lower pole right renal cyst and 35 mL was removed
from the upper pole left renal cyst. 7 mL was removed the lower pole
left renal cyst.

Postprocedure scanning showed complete resolution of all cystic
structures without evidence of residual cystic lesion identified. There
are cortical atrophic changes related to long-standing suggest present.
There were no signs of complication. The patient exhibited minimal pain
during the procedure which was well tolerated. Sterile dressings were
applied. The patient tolerated the procedure well with no immediate
complications and was discharged from the procedure in stable condition.


IMPRESSION: Successful CT guided aspiration and ablation of 4 renal
cysts as described.

Thank you for referring patient to Interventional Radiology for their
procedure and allowing me to participate with you in their care.
________________________________________

http://www.zhealthpublishing.com/free_medical_coding_info/free_coding_newsletter/archive/201101.htm

Can someone verfy my codes for me? My main question is... would you code the surgical code once per cyst?

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