We are not sure what we should code for this procedure. Any help would be greatly appreciated.
Name of Procedure: Opening up of his automatic implantable cardioverter defibrillator pocket which had been derided with the removal of his automatic implantable cardioverter defibrillator. He had developed considerable bleeding. Repacking did not stop, nor did pressure.
Procedure Note: He was brought to the laboratory and he was draped in the usual fashion. The original incision site was reopened, and also a T incision down to where the perforation of the pocket had taken place. It was pulled back. All the thrombus was removed. It was irrigated. There was back-bleeding through an original site of a lead entry, and that was purse-string sutured. Cautery was carried out throughout the pocket. it was then closed with Polysorb in an inverted mattress manner. it was packed with iodoform guaze. It also had a drain put in place.
Assessment: Successful opening of the pocket, suturing
Name of Procedure: Opening up of his automatic implantable cardioverter defibrillator pocket which had been derided with the removal of his automatic implantable cardioverter defibrillator. He had developed considerable bleeding. Repacking did not stop, nor did pressure.
Procedure Note: He was brought to the laboratory and he was draped in the usual fashion. The original incision site was reopened, and also a T incision down to where the perforation of the pocket had taken place. It was pulled back. All the thrombus was removed. It was irrigated. There was back-bleeding through an original site of a lead entry, and that was purse-string sutured. Cautery was carried out throughout the pocket. it was then closed with Polysorb in an inverted mattress manner. it was packed with iodoform guaze. It also had a drain put in place.
Assessment: Successful opening of the pocket, suturing