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Can someone help with this note. I think I'm over thinking it. CVC line was placed, malposition and was ultimately removed. Would I code for insertion or removal or both?? Below is the procedure note.


Consent:
Consent obtained: Emergent situation
Consent given by: Healthcare agent
Risks discussed: Arterial puncture, incorrect placement, nerve damage, pneumothorax, infection and bleeding
Alternatives discussed: No treatment, delayed treatment, alternative treatment, observation and referral
Pre-procedure details:
Hand hygiene: Hand hygiene performed prior to insertion
Sterile barrier technique: All elements of maximal sterile technique followed
Skin preparation: 2% chlorhexidine
Skin preparation agent: Skin preparation agent completely dried prior to procedure
Sedation:
Sedation type: Deep
Anesthesia (see MAR for exact dosages):
Anesthesia method: None
Procedure details:
Location: R internal jugular
Patient position: Flat
Procedural supplies: Triple lumen
Catheter size: 7.5 Fr
Landmarks identified: yes
Ultrasound guidance: yes
Number of attempts: 1
Successful placement: no
Post-procedure details:
Post-procedure assessment: CVC with anomalous course on plain films, CVC subsequently removed. No pneumothorax.


CVC malpositioned, and removed. PICC order placed for patient.
 
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