# Please Help - spontaneous return by gravity.



## michea (Aug 26, 2009)

I'm an ASC coder and we are starting to see this more and more in the ASC.  Please advise b/c I am stumped!

OPERATIVE REPORT


DX;  S/P placement of Moncrief-Popovich PD catheter.  For externalization


Procedure:  Externalization of PD catheter


Surgeon:         ASST: 


ANES:  MAC with local anesthesia


COMPLICATIONS:  None.


Findings:  Liquified hematoma;  Catheter functions well with inflow by gravity at rate > 120 cc/min and spontaneous return by gravity.


DESCRIPTION OF PROCEDURE:
Ms Whittaker was seen in the holding area and appropriately identified.  She was then taken to the OR and placed supine on the operating table.


Following intravenous sedation, the skin of the anterior abdominal wall was cleaned, painted with Duraprep and sterile drapes were applied in the usual manner.


The previous "tattooed" site in the left lower abdomen was identified and this area was infiltrated with 1% xylocaine.  A short transverse incision was made through the skin into the subcutaneous tissues and by means of blunt dissection, the catheter was identified in the subcutaneous tissues.  With appropriate retraction, the cap was identified and grasped and elevated into the wound.  Liquified hematoma was encountered and was suctioned away.  Area was compressed and irrigated and no further fluid was obtained.  


The catheter was inspected and appeared to be free to the level of the first cuff in the subcutanous tissues. No further dissection along the catheter was performed.


The cap was removed and the catheter was aspirated of some fibrinous debris.  The catheter was flushed with heparinized saline solution.  A 60 cc syringe with hep/saline was attached to the catheter and allowed to drain by gravity.  Flow was noted to be Slightly sluggish, but > 100 mm/min.  There was spontaneous return of effluent.


The catheter was then flushed with hep/saline solution and recapped.


The skin on the medial side of the catheter was reapproximated with a single interrupted subcuticular suture of 4-0 vicryl.
Steristips were applied afterwhich bacitracin ointment was placed at the exit site and sterile dressing applied.


The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition


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## gerry (Jul 13, 2011)

Was this ever researched......I have the same scenerio...and can not find a CPT code for billing...any help will be appreciated


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## preserene (Jul 13, 2011)

I understand the scenario of your case this way:

*This is externalisation of already embedded subcutaneous segment of Intraperitoneal catheter which goes for the Code 49436..*.
The purpose fo the procedure is to create an exit system which is functioning.

I am trying to explain the steps of externalisation in simple words. You please read my words and read your operative steps also. If it makes sense and the same sense, and if convinced , then you can contemplate to go for this code.
[Aspiration and flushing  I  feel, becomes acomponent of the procedure].

Here I go:

' Externalisation procedure for  PD catheter-
Tunneling the catheter by selecting the exite site at a point 2cms external to the subcutaneous cuff which is already present there in this case in an arcuate fashion, in the case of Moncrief Pov. catheter( which is an EP design PD catheter). 
Now, a secondary incision is made by inserting a scalpel blade to the hub. A tunnelor tool or similar device is advanced through the subcut fat from the secondary incision(that is now made during this procedure) to the primary incision( before done fo rinsertion of the cathter).

The tip of the catheter is attached to the tunnelor and the tip brought through the secondary incision.
The above is the simplified words of the steps, done for externalization by creating an exite site.'

Now, do these steps correlate with the  procedure performed by your physician. 
However you query with your Surgeon whether it  is a procedure done as delayed creation of exit site from embedded subcutaneous sgement of IP catheter. if he agrees with, then you could go ahead with this code *49436*.

I hope this helps in our process of research.
Thank you for your time


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