Stuck on this one -36590?

codedog

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How would you code this one , Stuck on this, booking was 36590 put that includes port also , any ideas ?

PREOPERATIVE DIAGNOSIS: Duodenal ampullary carcinoma.

POSTOPERATIVE DIAGNOSES: Duodenal ampullary carcinoma and port adhered.

PROCEDURE PERFORMED: Total removal of Port-A-Cath was unsuccessful, only removal of part of the catheter.

OPERATIVE PROCEDURE: After appropriate informed consent was signed, the patient was taken to the operating room and was transferred to the operating table, underwent general anesthesia with successful endotracheal intubation. The area was prepped and draped in normal fashion. A time-out had been performed by me to ensure the correct patient and the correct procedure. Incision was made over the previous area. _____ (0:35) was obtained. The capsule was incised. The port was then removed. Upon trying to remove the catheter, it was removed for about 1-2 inches with pulling. This was done two to three times. I did not elect to do this any further because it was probably there for 5-6 years and most likely involved the major vascular structure. As most of the catheter was removed and then cut, the area was oversewn with 3-0 Vicryl and the Port-A-Cath was removed. The area was irrigated and closed with 3-0 nylon. A sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
Thank you for your time :)
 

cblack712

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It appears as if the port was removed, and the physician feels that an ample amount of the cath was removed and satisfied that no other intervention would be needed to finish this procedure (gathering this from the part that said that the port-a-cath was removed) so I would use the 36590.
Had further intervention been needed to remove the cath I would use the 36590 with a 53 modifier.
 
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