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Hi,
We are having a confusion about this. My co-auditor would code 47537 for the removal of liver drain. I would code just 49424 for the abscess drain check because removal of liver drain is E/M code as per our Encoder. Any thoughts? Thank you so much
Reason For Exam
LIVER ABSCESS DRAIN CHECK;Abscess
IR Fistula Sinus Tract
IR Fistula Sinus Tract
PREOPERATIVE DIAGNOSIS: 64-year-old male with history of liver abscess x2 status post percutaneous drainage. He has less than 5 cc of drainage per catheter per day.
POSTOPERATIVE DIAGNOSIS: Same
COMPARISON: Prior tube check from June 29, 2016
OPERATOR:
PROCEDURE:
Liver abscess drain check and removal x2
TECHNIQUE: Following informed consent the patient was brought to interventional radiology and placed in a supine position. Both liver abscess drains were prepped and draped in usual sterile fashion. Contrast was injected through each drain and spot fluoroscopic images were obtained. Each drain was then cut and removed over wire.
FINDINGS: No significant residual abscess cavity.
FLUOROSCOPY TIME: 0.9 minutes
CONTRAST DOSE: 10 cc Omnipaque 300
ANESTHESIA: None
COMPLICATIONS: None.
SPECIMEN: None.
ESTIMATED BLOOD LOSS: None.
PATIENT STATUS: Stable.
IMPRESSION:
NO SIGNIFICANT RESIDUAL HEPATIC ABSCESS CAVITY. THEREFORE, BOTH DRAINS WERE CUT AND REMOVED.
We are having a confusion about this. My co-auditor would code 47537 for the removal of liver drain. I would code just 49424 for the abscess drain check because removal of liver drain is E/M code as per our Encoder. Any thoughts? Thank you so much
Reason For Exam
LIVER ABSCESS DRAIN CHECK;Abscess
IR Fistula Sinus Tract
IR Fistula Sinus Tract
PREOPERATIVE DIAGNOSIS: 64-year-old male with history of liver abscess x2 status post percutaneous drainage. He has less than 5 cc of drainage per catheter per day.
POSTOPERATIVE DIAGNOSIS: Same
COMPARISON: Prior tube check from June 29, 2016
OPERATOR:
PROCEDURE:
Liver abscess drain check and removal x2
TECHNIQUE: Following informed consent the patient was brought to interventional radiology and placed in a supine position. Both liver abscess drains were prepped and draped in usual sterile fashion. Contrast was injected through each drain and spot fluoroscopic images were obtained. Each drain was then cut and removed over wire.
FINDINGS: No significant residual abscess cavity.
FLUOROSCOPY TIME: 0.9 minutes
CONTRAST DOSE: 10 cc Omnipaque 300
ANESTHESIA: None
COMPLICATIONS: None.
SPECIMEN: None.
ESTIMATED BLOOD LOSS: None.
PATIENT STATUS: Stable.
IMPRESSION:
NO SIGNIFICANT RESIDUAL HEPATIC ABSCESS CAVITY. THEREFORE, BOTH DRAINS WERE CUT AND REMOVED.