talitha82
Guest
Hi- I am fairly new to IR coding. I have a provider who did the following procedure in the office and I want to make sure I choose the correct code for it. Can anyone give me suggestions?
The patient is "four days status post left great saphenous vein EVLT and ambulatory phlebectomy with extreme pain and ultrasound documenting areas of dilated blood filled superficial varicosities. Also, increased ankle swelling with ultrasound demonstrating multiple increased sized dilated superficial incompetent varicosities around the left medial malleolus."
Doctor than goes on to perform:
The left leg was steriely prepped and draped in the usual sterile fashion. Three superficial dilated blood filled partially echogenic varicosities were accessed with an 18 gauge needle attached to a 10 cc syringe. Small amounts of blood were aspirated and squeezed from that, one of the three areas that caused the medial paid relief. Only approximately 5 cc of old blood was aspirated successfully.
Next, ultrasound guidance was used to access two seperate very dilated branching superficial varicosities around the left medial malleolus with a total of 3 cc of Asclera 1% injected which was milked proximally and distally.
Impression:
Successful ultrasound guided micro-thrombectomy of the left leg.
Successful ultrasound guided sclerotherapy utilizing Asclera 1%, 3 cc total, in two seperate dilated branching superficial varicosities in the left medial malleolar region.
The patient is "four days status post left great saphenous vein EVLT and ambulatory phlebectomy with extreme pain and ultrasound documenting areas of dilated blood filled superficial varicosities. Also, increased ankle swelling with ultrasound demonstrating multiple increased sized dilated superficial incompetent varicosities around the left medial malleolus."
Doctor than goes on to perform:
The left leg was steriely prepped and draped in the usual sterile fashion. Three superficial dilated blood filled partially echogenic varicosities were accessed with an 18 gauge needle attached to a 10 cc syringe. Small amounts of blood were aspirated and squeezed from that, one of the three areas that caused the medial paid relief. Only approximately 5 cc of old blood was aspirated successfully.
Next, ultrasound guidance was used to access two seperate very dilated branching superficial varicosities around the left medial malleolus with a total of 3 cc of Asclera 1% injected which was milked proximally and distally.
Impression:
Successful ultrasound guided micro-thrombectomy of the left leg.
Successful ultrasound guided sclerotherapy utilizing Asclera 1%, 3 cc total, in two seperate dilated branching superficial varicosities in the left medial malleolar region.