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Need help with OP note

  1. #1
    Question Need help with OP note
    Medical Coding Books
    Please help with coding for this OP note. I am new to Cardiovascular coding and am not sure what code, if any, to use for the ultrasound guidance.

    Date of Operation: 3/10/2009

    PreOp Dx: Deep venous thrombosis with pulmonary embolism
    Need for knee surgery

    Post OP DX: same as above

    Operation: Insertion of inferior vena cava filter

    Anesthesia: Local monitored anesthesia care

    INDICATION: This patient is a _______ with a history of recurrent DVT and PE. PT is due to undergo knee surgery and is going to need to be off Coumadin for several days perioperatively. Given the fact that PT has developed PEs while being off Coumadin for other procedures, we have brought PT to the operating room for placement of an inferior vena cava filter.

    FINDINGS: The filter is in good position just below the renals and the inferior verna cava.

    PROCEDURE: Consent was obtained. Patient was taken to the endo suite and placed supine on the fluoroscopy table. Under heavy sedation, both groins were prepped and drapped in usual sterile fashion. Using ultrasound guidance, the femoral veins were located. The right one appeared to be quite sclerotic from old DVT. Therefore, I went on the left side. I cannulated the vein under direct vision with ultrasound using a micropuncture technique. I eventually got our delivery sheath up into the cava. A cavogram was performed. The renals were marked. A Tulip filter was deployed just below the renals. Completion cavogram demonstrated good position. The shealth was pulled. Pressure was held until hemostatic. The patient tolerated the procedure well.

    Thanks in advance for any help with this.
    Peggy Y, Green, CPC, CPMA, CPC-I, CRC
    "To love what you do and feel that it matters - how could anything be more fun?" Katharine Graham

  2. #2

  3. #3
    Default Need Help with OP note
    Thank you.
    Peggy Y, Green, CPC, CPMA, CPC-I, CRC
    "To love what you do and feel that it matters - how could anything be more fun?" Katharine Graham

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