Need Help coding Aborted PAVF creation

LaSandra

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Please review the following note:

Procedure:

Informed consent was obtained. Monitoring of the patient before, during and after the procedure was performed. Blood Pressure, ECG, Respiration and Oxygen Saturation were measured and recorded at the intervals determined by protocol. The neck and extremity was prepped and draped in the usual sterile fashion.

Under ultrasound, the supraclavicular brachial plexus was identified. Local anesthetic was injected into the skin for a small wheal. The peripheral block needle was then introduced and advanced under real time ultrasound guidance. Once the needle was positioned around the nerve bundles, aspiration confirmed no blood return. Regional anesthetic was deposited around the nerves bundles. The needle was removed. The patient tolerated the procedure without any immediate complications. The entire procedure was done under real-time ultrasound guidance.

The cephalic vein was cannulated using the micropuncture needle. The needle was advanced down the perforating vein adjacent to the proximal ulnar artery. An attempt was made in crossing into the ulnar artery. However, significant venous spasm happened at this point. Imaging became poor quality and difficult to localize. The needle was removed, and hemostasis achieved. The procedure was now aborted.
 
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