Help with OP note
PLease advise on the correct codes to use. I am new to IR coding and am not sure about this.
PreOperative/PostOperative Dx: Venous gangrene of the right foot
INDICATIONS FOR SURGERY/PROCEDURE: The patient is a 68 year old male with past history significant for non small cell carcinoma of lung. He presents with 24 hours of right foot pain. Duplex exam of his right lower extremity showed good arterial in flow, however, he does have a noted clot in his tibial veins as well as his popliteal vein. He comes to the operating room today for possible percutaneous mechanical thrombectomy of his posterior tibial veins to help alleviate occlusion of his distal right leg. The patient understood the risks and benefits of the procedure and subsequently consented to it.
PROCEDURE IN DETAIL: After proper consent and permit secured on the chart, the patient was brought to the operating room. The patient was placed prone. He was sedated at this time. His right posterior popliteal fossa was prepped and draped in the standard sterial fashion as well as his posterior calf. With the aid of ultrasound, the posterior tibial vein was entered at this time. Multiple attempts at advancing the wire into the posterior tibial vein were unsuccessful and this access was abandoned. A micro puncture needle was then used and the popliteal vein was accessed at this time. A venogram was obtained from this position using a catheter placed in the external iliac vein and injecting proximally to the inferior vena cava as well as with the catheter placed into the common femoral vein and injecting into the more distal veins as well as through the sheath (this was three different locations for three different venograms). This exam showed that he was widely patent from his fermoral vein to his external iliac vein to his common iliac vein to the inferior vena cava. That is, there was no obvious clot in these named veins. At this point, all efforts were ceased at this time, and the patient will be managed expectantly.
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