Wiki Help with this op note, never had one like this

donna3679

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Doesn't look like doctor did any surgery, just ultrasound and video fluoroscopy..... looked up video fluoroscopy was not done with swallow test.

HOW DO I CODE THIS????? PLEASE HELP.
Procedure: examination under anesthesia, with ultrasound and fluoroscopy
the patient was brought back to surgery, and placed on the table in supine position. Light sedation with MAC was instituted by anesthesia. Using US, the patient's right chest wall was closely inspected, from the axilla to the iliac crest. We were unable to visualize any foreign objects, rib fractures, or other abnormalities. We then repeated the examination, this time with video fluoroscopy. After placement of the C-arm, the right chest and abdomen were thoroughly inspected, and no foreign objects were identified. We focused both modalities at the area marked by the patient as containing the fragment/bullet, but both modalities showed no abnormal findings.

After failing to find any objects to remove, the procedure was concluded. The patient was transferred to recovery in stable condition.
 
I would code a ultrasound of the chest wall CPT 76604.26 + 71045.26 (chest xray) + 74018.26 (abdomen xray).

After failing to find any objects to remove, the procedure was concluded. Meaning, no need for a surgery after the above CPT mention was done.
 
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