stogsmom3
Networker
My provider removed a syringe needle from a patients vein. I need help finding the correct CPT code. I feel he did more than CPT 10120. See the Op note below.
PREOPERATIVE DIAGNOSIS: Foreign body in the left upper extremity.
POSTOPERATIVE DIAGNOSIS: Syringe needle in the left upper extremity.
NAME OF PROCEDURE: Removal of left upper extremity foreign body with fluoroscopic guidance.
ANESTHESIA: General.
FINDINGS: There was a TB needle stuck within the superficial vein in the left antecubital area. Fluoroscopy was used to confirm there were no other pieces of metal in that area following removal. There was a very cord-like vein underneath the vein that had the needle stuck in it.
TECHNIQUE: The patient was taken to the operating room and placed supine on the operating table. The left upper extremity was prepped and draped in a standard surgical fashion. Local anesthetic was injected over the area where the needle could be felt. A small incision was made at this location. Scissors were used to dissect down to the vein containing the needle. The vein was looped proximally and distally with a 2-0 silk suture. The vein was opened up with the scissors, and the hypodermic needle was removed with a hemostat. The 2 previously placed loop sutures were tied. There was no bleeding. Fluoroscopy was then used to confirm that no other metal objects could be seen in the antecubital space. The incision was then reapproximated with a running 4-0 Vicryl subcuticular stitch. The wound was cleaned and dried, and Steri-Strips were applied. The patient tolerated the procedure well.[/COLOR]
PREOPERATIVE DIAGNOSIS: Foreign body in the left upper extremity.
POSTOPERATIVE DIAGNOSIS: Syringe needle in the left upper extremity.
NAME OF PROCEDURE: Removal of left upper extremity foreign body with fluoroscopic guidance.
ANESTHESIA: General.
FINDINGS: There was a TB needle stuck within the superficial vein in the left antecubital area. Fluoroscopy was used to confirm there were no other pieces of metal in that area following removal. There was a very cord-like vein underneath the vein that had the needle stuck in it.
TECHNIQUE: The patient was taken to the operating room and placed supine on the operating table. The left upper extremity was prepped and draped in a standard surgical fashion. Local anesthetic was injected over the area where the needle could be felt. A small incision was made at this location. Scissors were used to dissect down to the vein containing the needle. The vein was looped proximally and distally with a 2-0 silk suture. The vein was opened up with the scissors, and the hypodermic needle was removed with a hemostat. The 2 previously placed loop sutures were tied. There was no bleeding. Fluoroscopy was then used to confirm that no other metal objects could be seen in the antecubital space. The incision was then reapproximated with a running 4-0 Vicryl subcuticular stitch. The wound was cleaned and dried, and Steri-Strips were applied. The patient tolerated the procedure well.[/COLOR]