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Help coding this op report

  1. Default Help coding this op report
    Medical Coding Books
    Any help I could get coding this op report would be appreciated! The physician and I have been over the coding books. Thanks.

    Preoperative Diagnosis: Broken Intravenous Catheter with Retained Catheter in the Cephalic Vein
    Postoperative Diagnosis: Broken Intravenous Catheter with Retained Catheter in the Cephalic Vein

    1. Exploration of the forearm with fluoroscopy.
    2. Retrieval of Broken Catheter

    Indications: Pt had an IV in his right antecubital cephalic vein. When the hub on the catheter was removed because it was leaking blood, there was no catheter attached to the hub. I tried to retrieve the broken catheter using fluoroscopy in the pt's room with a small incision in the antecubital fossa: however, the catheter migrated distally into the midforearm. I decided to bring the pt to the operating room.

    Procedure: The patient was placed on the operating table with his arm on an arm table. Fluoroscopy was used to immediately confirm the location of the catheter in the midforearm in the cephalic vein. The arm was carefully prepped with Betadine paint and draped sterilely. The skin and subcutaneous tissue were then infiltrated with 1% Xylocaine.
    Using fluoroscopy to guide the dissection, a cut-down was made directly on the cephalic vein where the catheter was. The vein was mobilized over a vessel loop, and the catheter was then milked to the vessel loop where it was easily palpable.
    A venotomy was performed. The catheter was retrieved. The vein was ligated, and cautery was used to control minimal bleeding that was present
    The previous incision had not been closed on the floor before bringing the pt to the OR, so both those incisions were closed with interrupted Vicryl suture and interrupted Moncryl suture in subcuticular fashion. This was followed by Dermabond.

  2. #2
    Fayetteville, NC
    How about 37203 and 75961?
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  3. #3
    I agree with Grintwig's coding of this procedure.

  4. Default
    I appreciate both of your help with this! Rosie

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