Wiki help with procedure iliofemoral dvt right lower extremity with swelling and pain

slscott

New
Messages
4
Location
Shiprock, NM
Best answers
0
After obtaining informed consent, the patient was taken to the operative suite placed supine on the procedure table. A timeout was performed with the OR staff and physicians, correctly and then the patient, the site, and the procedure. Perioperative doses of antibiotics were given. She was placed under general anesthesia and then placed prone on the procedure table with all the correct padding.

The right popliteal space was prepped and draped in usual sterile fashion. Under ultrasound guidance I accessed the right popliteal vein and dilated up to a 6 French sheath. I was then able to get a wire and aqua tempo catheter into the external iliac vein but was unable to traverse the clot in the common iliac vein up into the IVC. After multiple wires and catheters and attempts, the procedure was aborted. I had upsized to a 7 French sheath which was a 55 cm sheath. The patient was given 5000 units of heparin during the procedure.

I then pulled the sheath and held pressure for 10 minutes on the popliteal space on the right side. A 4-0 Monocryl was utilized to place interrupted dermal sutures at the skin at my small incision and then sterile dressings were placed as well as a large Ace bandage on the leg.

All final instrument and sponge counts were correct x2. She will be discharged home with appropriate instructions and I will see her back in clinic in 2 weeks to check her progress. We will resume her Eliquis this evening.
 
After obtaining informed consent, the patient was taken to the operative suite placed supine on the procedure table. A timeout was performed with the OR staff and physicians, correctly and then the patient, the site, and the procedure. Perioperative doses of antibiotics were given. She was placed under general anesthesia and then placed prone on the procedure table with all the correct padding.

The right popliteal space was prepped and draped in usual sterile fashion. Under ultrasound guidance I accessed the right popliteal vein and dilated up to a 6 French sheath. I was then able to get a wire and aqua tempo catheter into the external iliac vein but was unable to traverse the clot in the common iliac vein up into the IVC. After multiple wires and catheters and attempts, the procedure was aborted. I had upsized to a 7 French sheath which was a 55 cm sheath. The patient was given 5000 units of heparin during the procedure.

I then pulled the sheath and held pressure for 10 minutes on the popliteal space on the right side. A 4-0 Monocryl was utilized to place interrupted dermal sutures at the skin at my small incision and then sterile dressings were placed as well as a large Ace bandage on the leg.

All final instrument and sponge counts were correct x2. She will be discharged home with appropriate instructions and I will see her back in clinic in 2 weeks to check her progress. We will resume her Eliquis this evening.
Would that just be 36000 since no intervention or selective catheter placement was performed.
 
i figure it would be the where the catheter was placed at the popliteal vein or iliac vein with modifier 53?
If a surgical or diagnostic procedure had been started and then terminated due to the patient's well-being you would use that diagnostic/intervention code with a 53 modifier. Since no intervention was able to be done, 36000 covers the catheter placement that was performed.

Hope this helps!
 
If a surgical or diagnostic procedure had been started and then terminated due to the patient's well-being you would use that diagnostic/intervention code with a 53 modifier. Since no intervention was able to be done, 36000 covers the catheter placement that was performed.

Hope this helps!
thank you
 
Top