Not sure how to code this... My doc did not put the line in. Would I use 36589? The patient was a transfer from another hospital:
PROCEDURES:
1. Left arterial line removal.
2. Hemostasis.
3. FemoStop.
HISTORY AND INDICATIONS: The patient has severe peripheral arterial and coronary artery disease. She presents a <<__>> septic picture and had necrotic right foot, second and third toes. The patient also had sepsis likely from her hemodialysis catheter and C. difficile colitis as well. She was found to have new EKG changes during her septic shock event.
She also had slightly abnormal troponin. The patient also had necrotic right foot as described above. Plan was to have attempt at improving circulation to the right foot and possibly also do the coronary angiogram to see if some intervention could benefit her on the coronary site even though the patient is known to have severe disease of both areas. The primary focus was
supposed to be the right leg.
The patient has A-line in the left femoral artery. The A-line was small caliber and very low stick. We passed the wire through the A-line but only 0.018 wire would fit. This wire did not give us support; exchanged for a 4-French sheath or 5-French sheath or 6-French sheath despite multiple attempted. The wire was removed. We held pressure and we are going to apply the
FemoStop for hemostasis. The patient is going to be taken BUN and back the patient her room.
There was no other access available. She <<__>> a severe stenosis about 70% at least in the left subclavian artery. The right radial pulse could not be palpated and the right femoral artery is known to have a stent across the femoral access area. The patient is going to be sent back to her ICU room and we are going to evaluate at a later time.
Thanks for any help!
Jennifer Everett, CPC-A
PROCEDURES:
1. Left arterial line removal.
2. Hemostasis.
3. FemoStop.
HISTORY AND INDICATIONS: The patient has severe peripheral arterial and coronary artery disease. She presents a <<__>> septic picture and had necrotic right foot, second and third toes. The patient also had sepsis likely from her hemodialysis catheter and C. difficile colitis as well. She was found to have new EKG changes during her septic shock event.
She also had slightly abnormal troponin. The patient also had necrotic right foot as described above. Plan was to have attempt at improving circulation to the right foot and possibly also do the coronary angiogram to see if some intervention could benefit her on the coronary site even though the patient is known to have severe disease of both areas. The primary focus was
supposed to be the right leg.
The patient has A-line in the left femoral artery. The A-line was small caliber and very low stick. We passed the wire through the A-line but only 0.018 wire would fit. This wire did not give us support; exchanged for a 4-French sheath or 5-French sheath or 6-French sheath despite multiple attempted. The wire was removed. We held pressure and we are going to apply the
FemoStop for hemostasis. The patient is going to be taken BUN and back the patient her room.
There was no other access available. She <<__>> a severe stenosis about 70% at least in the left subclavian artery. The right radial pulse could not be palpated and the right femoral artery is known to have a stent across the femoral access area. The patient is going to be sent back to her ICU room and we are going to evaluate at a later time.
Thanks for any help!
Jennifer Everett, CPC-A
