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Can Someone Help Me in Coding the following Documentation:
Patient Is Older than 5 YRS OLD
Date of procedure: 01/18/24
Pre-op diagnosis: End-stage renal disease and the need for CVVHD.
Post-op diagnosis: same
Procedure Performed: femoral dialysis catheter
Procedure:
PROCEDURE: Hemodialysis catheter placement in the left femoral vein under direct visualization utilizing the Doppler ultrasound technique.
REASON FOR PROCEDURE: End-stage renal disease and the need for CVVHDPROCEDURE IN DETAIL: Emergency procedure after cardiac arrest.
patient was laid in supine position. The left femoral vein area was cleaned with chlorhexidine and the skin and subcutaneous tissue were anesthetized with 5 mL of 1% lidocaine. Left femoral vein was recognized as a compressible vessel utilizing the Doppler ultrasound technique. It was cannulated on the 1st attempt without any difficulty. A good blood flow from the needle hub was obtained. The guide wire was inserted via the needle into the left femoral vein then, the needle was removed. The tract was dilated using the dilators of the HD catheter kit. The dilators then were removed. The HD catheter was inserted over the guide wire into the left femoral vein then the guide wire was removed gingerly. A good blood flow from all lumens was obtained. The lumens were flushed with saline and the hub was sutured to the skin. There were no changes in hemodynamics, oxygenation, or bleeding at the site. The patient tolerated the procedure well. A 16 cm 12 French HD catheter was in the left femoral vein. KUB was ordered and showed the tip in satisfactory position.
Anesthesia: local
Surgeon: XXXXXXXXX
Estimated blood loss: 2
Pathology: none sent
Condition: critical
Disposition: ICU
Patient Is Older than 5 YRS OLD
Date of procedure: 01/18/24
Pre-op diagnosis: End-stage renal disease and the need for CVVHD.
Post-op diagnosis: same
Procedure Performed: femoral dialysis catheter
Procedure:
PROCEDURE: Hemodialysis catheter placement in the left femoral vein under direct visualization utilizing the Doppler ultrasound technique.
REASON FOR PROCEDURE: End-stage renal disease and the need for CVVHDPROCEDURE IN DETAIL: Emergency procedure after cardiac arrest.
patient was laid in supine position. The left femoral vein area was cleaned with chlorhexidine and the skin and subcutaneous tissue were anesthetized with 5 mL of 1% lidocaine. Left femoral vein was recognized as a compressible vessel utilizing the Doppler ultrasound technique. It was cannulated on the 1st attempt without any difficulty. A good blood flow from the needle hub was obtained. The guide wire was inserted via the needle into the left femoral vein then, the needle was removed. The tract was dilated using the dilators of the HD catheter kit. The dilators then were removed. The HD catheter was inserted over the guide wire into the left femoral vein then the guide wire was removed gingerly. A good blood flow from all lumens was obtained. The lumens were flushed with saline and the hub was sutured to the skin. There were no changes in hemodynamics, oxygenation, or bleeding at the site. The patient tolerated the procedure well. A 16 cm 12 French HD catheter was in the left femoral vein. KUB was ordered and showed the tip in satisfactory position.
Anesthesia: local
Surgeon: XXXXXXXXX
Estimated blood loss: 2
Pathology: none sent
Condition: critical
Disposition: ICU
