# coding help - fluoroscopy and revision



## snjberry (Oct 21, 2011)

op note
preop diag:  right breast cancer
post op diag:  right breast cancer

procedure:  placement of right subclavian infuse-a-port tunneled and implanted under fluoroscopy and revision of chest wall scar.

indications:  This patient is a 48 yr old woman with right breast cancer who requires adjuvant chemotherapy.  She also has a hypertropic scar on her anterior chest wall.

Procedure:  The patient was put in the supine position.  The entire chest and neck was prepped and draped using the usual steril technique.  Attempts were made to gain acces to the left subclavian vein without success.  The blood returen was bright red and pulsatile suggesting a subclavian artery puncture.  Similar attempts were made in the left neck for a left jugular vein access without success.  A chest x-ray was obtained intraoperatively to exclude a pneumothorax.  There was no pneumothorax identified.  At this point a successful access to the right subclavian vein was accomplished.  A guide wire was advanced throug the needle and the needle withdrawn.  Fluoroscopy was used to confirm the guide wire was in the superior vena cava.  An incision was made sever centimeters inferior to the puncture site to accomodate the infuse-a-port reservoir.  A tunnerler was used to advance the tip of the 8.5 French single lumen infuse-a-port catheter from the incision site to the puncture site.  A break away sheath introducer was used to guide the tip of the catheter into the right suclavian vein.  The break away sheath was discarded.  Fluoroscopy confirmed that the tip of the catheter was in the superior vena cava.  The catheter withdrew blood easily and flushed easily with saline.  The catheter was connected to the infuse-a-port reservoir and the infuse-a-port was tacked to the anterior ches wall fascia with two fixation sutures of vicryl.  The reservoir and catheter were filled with heparinized saline.  The incision sites were closed with running subcuticular 4-0 vicryl sutures.  The previous anterior ches wall scar was then sharply excised and sent to pathology.  Hemostatis was achieved with suture ligatures and the wound was closed with a running 4-0 vicryl suture subcuticular.  Sterile dressings were applied to the wounds.  The patient was awake and hemodynamically stable post procedure.  All instruemnt and needle counts were accurate.  Astat portable chest exray was ordered for recovery room post procedure. 

any coding help would be helpful


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## ajs (Oct 21, 2011)

Look in CPT book section 36500 there was a Central Venous Access Procedures Table and a big page of discussion following it on the placement of central venous access devices of all types.  I think you will find the direction you are needing there.  ( Don't have my 2011 book with me, but in the 2010 book it was on pages 192 and 193 Surgery/Cardivascular System).


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## FTessaBartels (Oct 24, 2011)

*Re the Scar excision*

In addition to the tunneled CVL ... 

Scar revisions are coded one of two ways. 1) Complex repair;  -OR- 2)  Excision of lesion

From the procedural note you've provided, I'd be inclined to code it as an Excision of Lesion.  *However* you will need to ask the physician to dictate an addendum stipulating the size of the scar/lesion.  You cannot code without this information. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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