# 24 modifier and diagnosis for infiltration



## Elizabeth83 (Jul 19, 2013)

I'm trying to decide whether i should bill a consult with a -24 modifier for the patient's infiltrated arm or should it be included in the 90 post op period. What ICD-9 would you use for infiltration? or would you just use the hematoma code? Any suggestions would be helpful. 

Reason for consult: hematoma        Prior surgery 36821 on 5/21/13

_____is a 67-year-old female well-known
to our service from creation of a left upper arm arteriovenous fistula and
insertion of a tunneled dialysis catheter.  Apparently an attempt was made
yesterday to access her fistula for the first time.  This resulted in
infiltration and she now has a large hematoma on her left arm.  This is
painful but does not appear to be enlarging.  She is admitted to the
hospital for evaluation of her uncontrolled hypertension.


PAST MEDICAL HISTORY:  Her past medical history shows no allergies.


SERIOUS ILLNESSES:  Hypertension, end-stage renal disease and history of a
cerebrovascular accident.


REVIEW OF SYSTEMS:  Review of systems are entirely negative.


PHYSICAL EXAMINATION:  GENERAL APPEARANCE:  Exam shows a 67-year-old white
female in no acute distress.  VITAL SIGNS: Temperature is 99.1, blood
pressure 149/85, pulse 74, respirations 20.  HEAD, EYES, EARS, NOSE AND
THROAT:  Negative.  NECK:  Neck is supple.  LUNGS:  Lungs are clear.
HEART:  The heart has a normal rate and rhythm.  There is a tunneled
catheter placed in the right chest.  ABDOMEN:  Her abdomen is flat and
soft.  EXTREMITIES:  Show in the right upper extremity there is a large
hematoma.  There is a functioning arteriovenous fistula.  There is no
erythema.  NEUROLOGICALLY:  She is alert and oriented and answers questions
appropriately.


LABORATORY DATA:  Complete blood count has a white blood cell count of
7,200, hemoglobin is 9.8, hematocrit is 31.1 with a platelet count of
127,000.  Chemistry profile has sodium 140, potassium 5.7, chloride 101,
CO2 is 25.  Blood urea nitrogen is 33, creatinine 3.58 with a glucose of
110.  Liver function studies are all normal.  CPK (creatinine
phosphokinase) is less than 20.  Troponin is 0.035.  CT scan of the head
performed on 7/16/2013 shows some white matter changes consistent with
small-vessel ischemia.


IMPRESSION:
1. End-stage renal disease on hemodialysis.
2. Infiltrated right arm arteriovenous fistula with resultant hematoma and
   pain.
3. Hypertension.
4. History of cerebrovascular accident.
5. Gouty arthritis
6. History of avascular necrosis of her hips.


PLAN:  The fistula is obviously infiltrated and should be given a period of
time to recover. Therefore we will need to facilitate her dialysis with her
tunnel dialysis catheter.  For completeness however, we will ultrasound her
right upper extremity to evaluate for any further extravasations.


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