deivanaiv
Contributor
Hi,
Can any one help me in chosing the correct CPT for the below mentioned scenario? Please help me to identify whether this is an Inpatient or Out Patient.
EXAM: 10/13/2011 REMOVAL OF LIVER ABSCESS DRAIN
INDICATION: Multiloculated liver abscess status post percutaneous drainage
9/28/2011. The drain had either been removed or had fallen out by 10/2/2011,
but due to residual abscesses, another drain was placed 10/5/2011. The output
from this drain has ceased, but the patient is still suffering from right upper
quadrant/right chest wall pain and has an increasing right pleural effusion,
shortness of breath, and blood pressure lability. In addition, a CT of the
chest that was performed 10/12/2011 demonstrated that a separate component of
the abscess had increased from 2.2 x 3.5cm to 2.9 x 5.0cm. The collection that
the drain resided within has completely resolved.
ACCESS: Existing liver abscess drain.
SEDATION: None.
COMPLICATIONS: None.
PROCEDURE: The drain was unlocked by cutting off its hub. It was removed
completely intact. A sterile dressing was applied.
COMPARISON: Multiple prior imaging of the abdomen dating back to the ultrasound
of 9/22/2011 and most recently the CT of the chest of 10/12/2011.
FINDINGS: As above.
IMPRESSION: Successful removal of a liver abscess drain.
RECOMMENDATIONS: Because the patient is still symptomatic as detailed above and
there is a separate non drained component that is increasing in size, her
Coumadin will be stopped today on 10/13/2011, and she will be set up for
another drainage catheter placement on Monday, 10/17/2011, or Tuesday,
10/18/2011. In addition, the patient will have a diagnostic and therapeutic
right thoracentesis at that time.
Thanks,
Deivanai.
Can any one help me in chosing the correct CPT for the below mentioned scenario? Please help me to identify whether this is an Inpatient or Out Patient.
EXAM: 10/13/2011 REMOVAL OF LIVER ABSCESS DRAIN
INDICATION: Multiloculated liver abscess status post percutaneous drainage
9/28/2011. The drain had either been removed or had fallen out by 10/2/2011,
but due to residual abscesses, another drain was placed 10/5/2011. The output
from this drain has ceased, but the patient is still suffering from right upper
quadrant/right chest wall pain and has an increasing right pleural effusion,
shortness of breath, and blood pressure lability. In addition, a CT of the
chest that was performed 10/12/2011 demonstrated that a separate component of
the abscess had increased from 2.2 x 3.5cm to 2.9 x 5.0cm. The collection that
the drain resided within has completely resolved.
ACCESS: Existing liver abscess drain.
SEDATION: None.
COMPLICATIONS: None.
PROCEDURE: The drain was unlocked by cutting off its hub. It was removed
completely intact. A sterile dressing was applied.
COMPARISON: Multiple prior imaging of the abdomen dating back to the ultrasound
of 9/22/2011 and most recently the CT of the chest of 10/12/2011.
FINDINGS: As above.
IMPRESSION: Successful removal of a liver abscess drain.
RECOMMENDATIONS: Because the patient is still symptomatic as detailed above and
there is a separate non drained component that is increasing in size, her
Coumadin will be stopped today on 10/13/2011, and she will be set up for
another drainage catheter placement on Monday, 10/17/2011, or Tuesday,
10/18/2011. In addition, the patient will have a diagnostic and therapeutic
right thoracentesis at that time.
Thanks,
Deivanai.