# Removal of venous port



## tmr1965 (Aug 19, 2015)

I am coding for the very first time in general surgery.  If a patient comes into the office for removal of a venous port do I code an E&M code with the removal of the venous port or just the venous port code, and then do I code the non use of a venous port for the diagnosis?


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## cynthiabrown (Aug 19, 2015)

Just the port with dx v58.81


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## tmr1965 (Aug 19, 2015)

thank you and would I use 36590 when it doesn't say anything in the soap note other than patient had bilateral mastectomy and chemotherapy 5 years ago.She has had the venous port and wants it removed as she is in remission.


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## tmr1965 (Aug 19, 2015)

I was told that if he doesn't mention anything about the procedure in his soap note as far as being non tunneled or tunneled that you only code the E&M?


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## cynthiabrown (Aug 19, 2015)

Well if he didn't document it, no, you can't bill for it


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## cynthiabrown (Aug 19, 2015)

A non tunneled would not be in that long, but regardless if he didn't document procedure it is not billable


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