RadVCCoder
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I was wondering if anyone could provide feedback on the report I have pasted below. They are wanting me to bill out 10030 but I am conflicted on how it is via cath? Am I looking to deep into it?
EXAM:
US GUIDE FLUID ASP
INDICATION:
Abdominal Wall,Apixaban (Eliquis),0,s/p mons pubis lipoma excision, question
seroma,S/P excision of lipoma,S/P excision of lipoma
PROCEDURE:
The indications, material risks, and alternative of the procedure were
discussed and informed consent obtained.
Time-out procedure was performed. The area was examined and marked. The area
was prepped and draped in a sterile fashion. 1% lidocaine was used as local
anesthetic. Under ultrasound guidance an 18 gauge needle was introduced in to
the area of interest located just superior to the trans verse incision on the
left side. 15 mL of clear dark red fluid was obtained and sent for laboratory
analysis. Needle was removed and hemostasis was obtained. The area was
appropriately dressed with a bandage. The patient tolerated the procedure well
and there were no immediate complications.
IMPRESSION:
Ultrasound-guided fluid aspiration near a surgical incision of the mons pubis
yielding 15 mL of clear dark red fluid
EXAM:
US GUIDE FLUID ASP
INDICATION:
Abdominal Wall,Apixaban (Eliquis),0,s/p mons pubis lipoma excision, question
seroma,S/P excision of lipoma,S/P excision of lipoma
PROCEDURE:
The indications, material risks, and alternative of the procedure were
discussed and informed consent obtained.
Time-out procedure was performed. The area was examined and marked. The area
was prepped and draped in a sterile fashion. 1% lidocaine was used as local
anesthetic. Under ultrasound guidance an 18 gauge needle was introduced in to
the area of interest located just superior to the trans verse incision on the
left side. 15 mL of clear dark red fluid was obtained and sent for laboratory
analysis. Needle was removed and hemostasis was obtained. The area was
appropriately dressed with a bandage. The patient tolerated the procedure well
and there were no immediate complications.
IMPRESSION:
Ultrasound-guided fluid aspiration near a surgical incision of the mons pubis
yielding 15 mL of clear dark red fluid