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Must tunneled catheter be mentioned?

  1. Default Must tunneled catheter be mentioned?
    Medical Coding Books
    Hello all,

    Must the words "tunneled catheter" be mentioned in the doctor's dictation to bill 36561? I believe the content of his dictation supports the tunneled port code. Thoughts? Thanks! Sue

    IR MEDIPORT INSERTION

    PowerPort PLACEMENT RIGHT CHEST

    Indications:

    The patient is a 55-year-old female with a new diagnosis of stage III colorectal cancer. She is to undergo 6 month of chemotherapy.
    chnique:

    After the patient was identified in the preprocedure holding area and informed consent was obtained for a power port placement. Risks benefits and alternatives including but not limited to bleeding infection pain and pneumothorax were explained to the patient and she agreed to proceed. The patient was transferred to the angiography suite placed on the angiography table in supine position. Her chest and neck were prepped and draped in the standard surgical fashion. Maximal sterile barrier technique was used for this central access procedure. 1% lidocaine with epinephrine was infiltrated into the patient's right neck and chest area. Under ultrasound guidance. Ultrasound was used to image the right neck. The right internal jugular vein was shown to be patent. Hardcopy image was saved on PACS commencing the service. Using real-time ultrasound guidance a needle was placed into the right internal jugular vein. An 035 guidewire was inserted through this needle into the right atrium. A 3 cm incision was made on the patient's right anterior chest wall. A pocket was formed using blunt dissection. An introducer sheath was then placed over the wire through the right internal jugular vein to the patient's superior vena cava. Through this the Mediport catheter was advanced into the patient's right atrium. This was trimmed at 18 cm and attached to the Mediport. The Mediport was sutured to the anterior chest wall using 3-0 Vicryl suture. The pocket was then closed with a layer for a 3-0 Vicryl suture followed by a lateral 4 Monocryl suture to approximate the skin. A completion x-ray from good placement of the tip of the Mediport catheter the patient's right atrium with no kinking along the course of the catheter. The port was flushed with heparinized saline and there was adequate flow through the catheter.

    IMPRESSION:

    Successful placement of right internal jugular Mediport.

  2. #2
    Default
    Quote Originally Posted by suela923@aol.com View Post
    Hello all,

    Must the words "tunneled catheter" be mentioned in the doctor's dictation to bill 36561? I believe the content of his dictation supports the tunneled port code. Thoughts? Thanks! Sue

    IR MEDIPORT INSERTION

    PowerPort PLACEMENT RIGHT CHEST

    Indications:

    The patient is a 55-year-old female with a new diagnosis of stage III colorectal cancer. She is to undergo 6 month of chemotherapy.
    chnique:

    After the patient was identified in the preprocedure holding area and informed consent was obtained for a power port placement. Risks benefits and alternatives including but not limited to bleeding infection pain and pneumothorax were explained to the patient and she agreed to proceed. The patient was transferred to the angiography suite placed on the angiography table in supine position. Her chest and neck were prepped and draped in the standard surgical fashion. Maximal sterile barrier technique was used for this central access procedure. 1% lidocaine with epinephrine was infiltrated into the patient's right neck and chest area. Under ultrasound guidance. Ultrasound was used to image the right neck. The right internal jugular vein was shown to be patent. Hardcopy image was saved on PACS commencing the service. Using real-time ultrasound guidance a needle was placed into the right internal jugular vein. An 035 guidewire was inserted through this needle into the right atrium. A 3 cm incision was made on the patient's right anterior chest wall. A pocket was formed using blunt dissection. An introducer sheath was then placed over the wire through the right internal jugular vein to the patient's superior vena cava. Through this the Mediport catheter was advanced into the patient's right atrium. This was trimmed at 18 cm and attached to the Mediport. The Mediport was sutured to the anterior chest wall using 3-0 Vicryl suture. The pocket was then closed with a layer for a 3-0 Vicryl suture followed by a lateral 4 Monocryl suture to approximate the skin. A completion x-ray from good placement of the tip of the Mediport catheter the patient's right atrium with no kinking along the course of the catheter. The port was flushed with heparinized saline and there was adequate flow through the catheter.

    IMPRESSION:

    Successful placement of right internal jugular Mediport.
    I would agree with you that the report is supports the code, but I would get a note to the doctor that the report needs a statement that the catheter was tunneled from the port pocket to the jugular access.
    Thanks,
    Jim

  3. Default
    Thanks Jim!

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