Can we code the following procedure with 49021 & 75989-26 alone or do we need to add 49080 & 76942-26 also.Kindly confirm.
Ultrasound Guided Paracentesis:
Clinical history: 59-year-old male with lymphoma and intractable
ascites requiring weekly therapeutic paracentesis. Patient
referred for placement of a tunneled Tenckhoff peritoneal catheter
and therapeutic paracentesis.
Procedure:
Initial ultrasound images demonstrated a large pocket of ascitic
fluid with no evidence of superficial loops of bowel or
carcinomatosis in the left lower quadrant just inferior into the
left of the umbilicus. The skin was then marked at the expected
site are peritoneal entry.
The left lower quadrant was then prepped and draped in the usual
sterile fashion. Ultrasound was then used to reconfirm the site
of expected peritoneal entry. In addition, an approximate 15 cm
tract was marked and anesthetized with what was a lidocaine in the
left lower quadrant.
Under fluoroscopic guidance, an 18 gauge x 10 cm trochar needle
was then advanced into the subcutaneous tissues and along the
anesthetized tract. Careful attention was made not to advance the
needle into the dermis or penetrate the peritoneum.
A 5 cm curve was then placed on the distal tip of a 22 cm x 15 cm
diamond tipped needle. The needle was then coaxially loaded
through the 18 gauge trochar needle. With external pressure being
placed on the expected location of peritoneal entry, the 22 gauge
needle was advanced and used to gain access into the peritoneum.
The inner style that of the needle was removed and return of
cloudy yellow peritoneal fluid was identified. Fluoroscopic
images confirmed needle entry at the planned site of peritoneal
entry.
At only a wire was advanced through the 22 gauge needle and coiled
within the peritoneum. The needle was removed and exchanged for a
six French transition dilator which was advanced into the
peritoneum. The inner dilator was then removed and an Amplatz
wire was coaxially loaded through the transition dilator alongside
the 018 wire. The transition dilator was then removed. The inner
dilator was then readvanced over the 018 wire after which, the
wire was removed.
The transition dilator was then slowly drawn back while injecting
0 percent lidocaine with epinephrine to deliver further local
anesthesia to the tunnel tract.
Serial dilatation of the tract over the Amplatz wire was
performed. An 18 French peel-away sheath was then advanced over
the wire and positioned with its distal tip within the peritoneum.
The 15 French x 42 cm Tenckhoff catheter was coaxially loaded onto
a six French Berenstein catheter. The inner dilator of the peel
away sheath was removed and a rush of peritoneal fluid was
identified. The Berenstein catheter and Tenckhoff catheter were
then advanced over the wire and through the peel away sheath. The
total sheath was then removed. The catheter was positioned within
the peroneal with its cuff approximately 2 cm within the tunnel
tract. The Berenstein catheter and wire were then removed and a
rush of peritoneal fluid from the Tenckhoff catheter was
identified. No leakage around the catheter tract was identified.
The catheter was then attached to gravity drainage and secured to
the skin with 2 0 prolene suture. Bacitracin ointment and a
biopatch was placed over the catheter at its skin entry site and a
sterile dressing was applied.
The patient was brought to the recovery room where 10 liters of
cloudy yellow fluid was aspirated. During paracentesis the
patient received 225 ml of 25% albumin.
The patient tolerated the procedure well and was discharged home
in stable condition. There are no immediate complications.
Impression:
Successful placement of a 15 French x 42 cm tunneled Tenckhoff
peritoneal drainage catheter in the left lower quadrant as
described above.
Successful aspiration of approximately 10 liters of cloudy yellow
peritoneal fluid as described above.
Ultrasound Guided Paracentesis:
Clinical history: 59-year-old male with lymphoma and intractable
ascites requiring weekly therapeutic paracentesis. Patient
referred for placement of a tunneled Tenckhoff peritoneal catheter
and therapeutic paracentesis.
Procedure:
Initial ultrasound images demonstrated a large pocket of ascitic
fluid with no evidence of superficial loops of bowel or
carcinomatosis in the left lower quadrant just inferior into the
left of the umbilicus. The skin was then marked at the expected
site are peritoneal entry.
The left lower quadrant was then prepped and draped in the usual
sterile fashion. Ultrasound was then used to reconfirm the site
of expected peritoneal entry. In addition, an approximate 15 cm
tract was marked and anesthetized with what was a lidocaine in the
left lower quadrant.
Under fluoroscopic guidance, an 18 gauge x 10 cm trochar needle
was then advanced into the subcutaneous tissues and along the
anesthetized tract. Careful attention was made not to advance the
needle into the dermis or penetrate the peritoneum.
A 5 cm curve was then placed on the distal tip of a 22 cm x 15 cm
diamond tipped needle. The needle was then coaxially loaded
through the 18 gauge trochar needle. With external pressure being
placed on the expected location of peritoneal entry, the 22 gauge
needle was advanced and used to gain access into the peritoneum.
The inner style that of the needle was removed and return of
cloudy yellow peritoneal fluid was identified. Fluoroscopic
images confirmed needle entry at the planned site of peritoneal
entry.
At only a wire was advanced through the 22 gauge needle and coiled
within the peritoneum. The needle was removed and exchanged for a
six French transition dilator which was advanced into the
peritoneum. The inner dilator was then removed and an Amplatz
wire was coaxially loaded through the transition dilator alongside
the 018 wire. The transition dilator was then removed. The inner
dilator was then readvanced over the 018 wire after which, the
wire was removed.
The transition dilator was then slowly drawn back while injecting
0 percent lidocaine with epinephrine to deliver further local
anesthesia to the tunnel tract.
Serial dilatation of the tract over the Amplatz wire was
performed. An 18 French peel-away sheath was then advanced over
the wire and positioned with its distal tip within the peritoneum.
The 15 French x 42 cm Tenckhoff catheter was coaxially loaded onto
a six French Berenstein catheter. The inner dilator of the peel
away sheath was removed and a rush of peritoneal fluid was
identified. The Berenstein catheter and Tenckhoff catheter were
then advanced over the wire and through the peel away sheath. The
total sheath was then removed. The catheter was positioned within
the peroneal with its cuff approximately 2 cm within the tunnel
tract. The Berenstein catheter and wire were then removed and a
rush of peritoneal fluid from the Tenckhoff catheter was
identified. No leakage around the catheter tract was identified.
The catheter was then attached to gravity drainage and secured to
the skin with 2 0 prolene suture. Bacitracin ointment and a
biopatch was placed over the catheter at its skin entry site and a
sterile dressing was applied.
The patient was brought to the recovery room where 10 liters of
cloudy yellow fluid was aspirated. During paracentesis the
patient received 225 ml of 25% albumin.
The patient tolerated the procedure well and was discharged home
in stable condition. There are no immediate complications.
Impression:
Successful placement of a 15 French x 42 cm tunneled Tenckhoff
peritoneal drainage catheter in the left lower quadrant as
described above.
Successful aspiration of approximately 10 liters of cloudy yellow
peritoneal fluid as described above.