KNLong
New
Procedure:
1. Removal of Port-A-Cath
2. Right chest wall scar revision (2.5 x 1 cm, skin and subcutaneous tissue)
Specimens: None
Estimated blood loss: Less than 5 mL
Blood replaced: None
Drains: None
Complications: None
Condition at the completion of the procedure: Stable
Findings:
Indwelling subcutaneous Port-A-Cath removed in its entirety.
Procedure in detail:
The patient's history and physical were updated prior to the procedure. She was transferred to the operating suite placed in the operating table where she underwent MAC. The chest was then prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
The soft tissues were injected with 1% Xylocaine for local anesthesia. An elliptical incision was then made around the previous scar. 2.5 x 1 cm of dermis and subcutaneous tissues were excised for scar revision. The subcutaneous tissues were then divided until the Port-A-Cath was identified. The port capsule was opened with electrocautery. The underlying Prolene sutures were cut and the Port-A-Cath was removed in its entirety. Once hemostasis was achieved, the capsule was then excised using electrocautery. The subcutaneous tissues were then reapproximated with 3-0 Vicryl. The deep dermis was reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well was transferred to recovery.
I am a new coder and I am trying to figure out if #2 in the procedure note would be included or not. My doctor does not ususally describe it this way and we just normally code the Port a Cath removal (36590). But I am curious to know if I should code it.
1. Removal of Port-A-Cath
2. Right chest wall scar revision (2.5 x 1 cm, skin and subcutaneous tissue)
Specimens: None
Estimated blood loss: Less than 5 mL
Blood replaced: None
Drains: None
Complications: None
Condition at the completion of the procedure: Stable
Findings:
Indwelling subcutaneous Port-A-Cath removed in its entirety.
Procedure in detail:
The patient's history and physical were updated prior to the procedure. She was transferred to the operating suite placed in the operating table where she underwent MAC. The chest was then prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
The soft tissues were injected with 1% Xylocaine for local anesthesia. An elliptical incision was then made around the previous scar. 2.5 x 1 cm of dermis and subcutaneous tissues were excised for scar revision. The subcutaneous tissues were then divided until the Port-A-Cath was identified. The port capsule was opened with electrocautery. The underlying Prolene sutures were cut and the Port-A-Cath was removed in its entirety. Once hemostasis was achieved, the capsule was then excised using electrocautery. The subcutaneous tissues were then reapproximated with 3-0 Vicryl. The deep dermis was reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well was transferred to recovery.
I am a new coder and I am trying to figure out if #2 in the procedure note would be included or not. My doctor does not ususally describe it this way and we just normally code the Port a Cath removal (36590). But I am curious to know if I should code it.