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Thread: aspiration of thrombus from the varicosities - 39 year old female with right lower

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    Default aspiration of thrombus from the varicosities - 39 year old female with right lower

    AAPC: Back to School
    Hi all:
    How to code this report,My codes are
    36000 59 453.40
    37187 453.40
    93965 2652 453.40

    Please confirm.
    History: 39 year old female with right lower extremity venous
    insufficiency status post successful sclerotherapy and
    embolization of a conglomeration of the varicosities within the
    calf returns for follow up examination.

    Mrs. XXX feels well. She notes some discomfort, tenderness
    and a "hard feeling" at the sclerotherapy injection sites.
    Physical examination of the right leg and foot demonstrates
    several palpable cords along the right upper anterior and lateral
    calf as well as the anterior mid calf. Doppler ultrasound
    examination of the right lower extremity veins demonstrates
    patency of the popliteal and posterior tibial veins. Previously
    sclerosed varicosities within the calf are thrombosed.

    The calf was then prepped with alcohol solution. Local anesthesia
    was administered to the tissue surrounding the thrombosed
    varicosities. Using 18 gauge needles and under real-time
    ultrasound guidance, aspiration of thrombus from the varicosities
    was performed. A large amount of thrombus was aspirated from the
    inferior varicosities; moderate thrombus was aspirated from the
    upper medial calf varicosities as the thrombus was not liquefied
    as yet. A compression dressing was applied to the site. The
    patient was advised to continue wearing her compression
    stocking.the patient is to return in one to two weeks. Further
    aspiration of thrombus will be performed at that time.
    Last edited by ank3t; 10-04-2016 at 05:55 AM.
    Shirley CPC,CPC-H

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