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  1. Question Inpatient/outpatient?
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    Can any one help me in chosing the correct CPT for the below mentioned scenario? Please help me to identify whether this is an Inpatient or Out Patient.


    INDICATION: Multiloculated liver abscess status post percutaneous drainage
    9/28/2011. The drain had either been removed or had fallen out by 10/2/2011,
    but due to residual abscesses, another drain was placed 10/5/2011. The output
    from this drain has ceased, but the patient is still suffering from right upper
    quadrant/right chest wall pain and has an increasing right pleural effusion,
    shortness of breath, and blood pressure lability. In addition, a CT of the
    chest that was performed 10/12/2011 demonstrated that a separate component of
    the abscess had increased from 2.2 x 3.5cm to 2.9 x 5.0cm. The collection that
    the drain resided within has completely resolved.
    ACCESS: Existing liver abscess drain.
    SEDATION: None.
    PROCEDURE: The drain was unlocked by cutting off its hub. It was removed
    completely intact. A sterile dressing was applied.

    COMPARISON: Multiple prior imaging of the abdomen dating back to the ultrasound
    of 9/22/2011 and most recently the CT of the chest of 10/12/2011.

    FINDINGS: As above.

    IMPRESSION: Successful removal of a liver abscess drain.
    RECOMMENDATIONS: Because the patient is still symptomatic as detailed above and
    there is a separate non drained component that is increasing in size, her
    Coumadin will be stopped today on 10/13/2011, and she will be set up for
    another drainage catheter placement on Monday, 10/17/2011, or Tuesday,

    10/18/2011. In addition, the patient will have a diagnostic and therapeutic
    right thoracentesis at that time.


  2. #2
    Milwaukee WI
    Default Part of E/M
    There is no code for this .... it's part of the E/M

    As for whether this is an inpatient or an outpatient ... YOU should know that based on where the service took place. If the patient was in the hospital, the hospital records can help you determine if the patient was admitted as an inpatient vs for observation (outpatient ... sometimes called "short stay")

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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