drhoads
Guru
Please help with correct cpt code on the following op report:
After obtaining informed consent and correctly identifying the pt, he was brought into the operative suite and placed in the supine postion. His left chest was shaved. His neck was rotated right and his left neck and chest were then prepped and draped in standard surgical fashion. The patient was placed in Trendelenburg position and the left neck was anesthetized. An anesthetization needle was used to locate the internal jugular vein. A large bore needle was placed into the vein and the wire placed. It was seen to enter the superior vena cava under fluoroscopic guidance. the patient was then placed to a neutral position. The tract between the stick site and the neck and the predetermined port site inferior to the left clavicle was anesthetized. Additionally the area at the left chest where the port was to be placed was anesthetized. A transverse incision was created. This was carried down to the catheter and passed from the neck to the chest incision. The dilator and sheath were then passed over the wire under fluoroscopic guidance. The dilator and wire were removed, leaving the sheath and the catheter was placed in this. The sheath was then split and removed. The catheter was positioned with its tip in the distal superior vena cava and a mosquito hemostat was placed on the port at the neck site to temporarily affix it there. Then 2-0 Prolene was placed laterally and mediallywithin the pocket for the port and attached to the port. The port was then place in the pocket. The catheter was cut to length and after having placed the cinch on it, it was threaded onto the port. The cinch was then place over top of this. It was secured to the pocket with 2-0 Prolene sutures. It was previously flushed with heparinized saline. The needle was then accessed into the Port and the port was seen to flush very well, but not dry easily. The hemostat had been taken off the neck, but it was felt there was still a kink there. The catheter was pushed deeper into the neck incision and this did then allow both drying and flushing of the port. Hemostatis was seen to be excellent. The dermis in the chest incision was then reapproximated 3-0 Vicryl in an interrupted fashion. The skin was then reapproximated with 4-0 Monocryl in a running subcuticular fashion. A single interruped 4-0 Monocryl suture was used to re approximate the small neck incision that had been made. The port was then accessed again and instilled with 5000 units of heparin which was left within the catheter proper. The wounds were washed and dried and benzoin and steri-strips were applied. Gauze and Tegaderm were placed over this. The patient tolerated the procedure well and left the operating room for the recovery room in stable condition.
Dx: Cholangiocarcinoma
Thanks
After obtaining informed consent and correctly identifying the pt, he was brought into the operative suite and placed in the supine postion. His left chest was shaved. His neck was rotated right and his left neck and chest were then prepped and draped in standard surgical fashion. The patient was placed in Trendelenburg position and the left neck was anesthetized. An anesthetization needle was used to locate the internal jugular vein. A large bore needle was placed into the vein and the wire placed. It was seen to enter the superior vena cava under fluoroscopic guidance. the patient was then placed to a neutral position. The tract between the stick site and the neck and the predetermined port site inferior to the left clavicle was anesthetized. Additionally the area at the left chest where the port was to be placed was anesthetized. A transverse incision was created. This was carried down to the catheter and passed from the neck to the chest incision. The dilator and sheath were then passed over the wire under fluoroscopic guidance. The dilator and wire were removed, leaving the sheath and the catheter was placed in this. The sheath was then split and removed. The catheter was positioned with its tip in the distal superior vena cava and a mosquito hemostat was placed on the port at the neck site to temporarily affix it there. Then 2-0 Prolene was placed laterally and mediallywithin the pocket for the port and attached to the port. The port was then place in the pocket. The catheter was cut to length and after having placed the cinch on it, it was threaded onto the port. The cinch was then place over top of this. It was secured to the pocket with 2-0 Prolene sutures. It was previously flushed with heparinized saline. The needle was then accessed into the Port and the port was seen to flush very well, but not dry easily. The hemostat had been taken off the neck, but it was felt there was still a kink there. The catheter was pushed deeper into the neck incision and this did then allow both drying and flushing of the port. Hemostatis was seen to be excellent. The dermis in the chest incision was then reapproximated 3-0 Vicryl in an interrupted fashion. The skin was then reapproximated with 4-0 Monocryl in a running subcuticular fashion. A single interruped 4-0 Monocryl suture was used to re approximate the small neck incision that had been made. The port was then accessed again and instilled with 5000 units of heparin which was left within the catheter proper. The wounds were washed and dried and benzoin and steri-strips were applied. Gauze and Tegaderm were placed over this. The patient tolerated the procedure well and left the operating room for the recovery room in stable condition.
Dx: Cholangiocarcinoma
Thanks