Shirleybala
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Hi,
How to code this report myy codes are
36478
36005 59
75820 26
Please confirm
The patient was brought into the procedure suite. Ultrasound
examination of the left lower extremity veins was performed
demonstrating occlusion of the greater saphenous vein below the
sapheno femoral junction. An incompetent perforator within the
upper thigh reconstitutes several superficial varicosities along
the medial fine. Communication with segments of the saphenous
vein are noted. Several large incompetent perforators are
identified within the calf, primarily arising from the posterior
tibial veins. The greater saphenous vein within the mid and lower
calf is patent an incompetent. A large conglomeration of
superficial varicosities is identified within the medial,
posterior aspect of the mid to upper calf.
The patient was then placed supine on the procedure table and the
leg prepped and draped in the usual sterile fashion. The
saphenous vein was accessed at the ankle under ultrasound guidance
using a 21 gauge micropuncture needle. The needle was exchanged
over a 0.018 inch guide wire for a 4 French tapered dilator. After
exchanging for a 0.035 inch guide wire, a five French 45 cm long
sheath was advanced to the mid calf. Venography was performed
demonstrating communication of the saphenous vein with large
incompetent perforators within the lower calf. An Angioynamics
laser fiber was then advanced through the sheath. Tumescent
anesthesia using .25% lidocaine solution was administered along
the entire course of the vein under ultrasound guidance.
Compression of the vein was noted throughout its course. After
redetermining that the tip of the fiber was below the
saphenofemoral junction, the laser was activated to the 10 Watts
energy and slowly withdrawn with the sheath. Total pullback time
was approximately 94 seconds. Total energy delivered was 1395 J.
Total vein length treated was 19 cm. The laser was deactivated
approximately 2 cm proximal to the puncture site. The sheath and
fiber were then removed. Repeat ultrasound exam demonstrates no
flow within the saphenous vein. The common femoral vein remains
patent. A grade 2 thigh high compression stocking was then
applied. The patient tolerated the procedure without incident.
Impression: Successful endovenous laser ablation of the left
greater saphenous vein within the calf as described above.
The patient is to return in one month for follow-up examination.
Sclerotherapy of incompetent perforators and superficial
varicosities, particularly adjacent to the medial malleolus will
be considered at that time.
How to code this report myy codes are
36478
36005 59
75820 26
Please confirm
The patient was brought into the procedure suite. Ultrasound
examination of the left lower extremity veins was performed
demonstrating occlusion of the greater saphenous vein below the
sapheno femoral junction. An incompetent perforator within the
upper thigh reconstitutes several superficial varicosities along
the medial fine. Communication with segments of the saphenous
vein are noted. Several large incompetent perforators are
identified within the calf, primarily arising from the posterior
tibial veins. The greater saphenous vein within the mid and lower
calf is patent an incompetent. A large conglomeration of
superficial varicosities is identified within the medial,
posterior aspect of the mid to upper calf.
The patient was then placed supine on the procedure table and the
leg prepped and draped in the usual sterile fashion. The
saphenous vein was accessed at the ankle under ultrasound guidance
using a 21 gauge micropuncture needle. The needle was exchanged
over a 0.018 inch guide wire for a 4 French tapered dilator. After
exchanging for a 0.035 inch guide wire, a five French 45 cm long
sheath was advanced to the mid calf. Venography was performed
demonstrating communication of the saphenous vein with large
incompetent perforators within the lower calf. An Angioynamics
laser fiber was then advanced through the sheath. Tumescent
anesthesia using .25% lidocaine solution was administered along
the entire course of the vein under ultrasound guidance.
Compression of the vein was noted throughout its course. After
redetermining that the tip of the fiber was below the
saphenofemoral junction, the laser was activated to the 10 Watts
energy and slowly withdrawn with the sheath. Total pullback time
was approximately 94 seconds. Total energy delivered was 1395 J.
Total vein length treated was 19 cm. The laser was deactivated
approximately 2 cm proximal to the puncture site. The sheath and
fiber were then removed. Repeat ultrasound exam demonstrates no
flow within the saphenous vein. The common femoral vein remains
patent. A grade 2 thigh high compression stocking was then
applied. The patient tolerated the procedure without incident.
Impression: Successful endovenous laser ablation of the left
greater saphenous vein within the calf as described above.
The patient is to return in one month for follow-up examination.
Sclerotherapy of incompetent perforators and superficial
varicosities, particularly adjacent to the medial malleolus will
be considered at that time.
Hello