codedog
True Blue
Stuck on this one. Patient had a port of cath, then came back thought was a revision of port a cath but turned out to be an evacuation of hematoma . Nowdoc did was flushed with saline. Do I still code it as a revision of port a cath(36576) o or just code evacuation of hematoma (10140) -any suggestions if neither or -thanks
PREOPERATIVE DIAGNOSIS: Breast carcinoma and Port-A-Cath hematoma.
POSTOPERATIVE DIAGNOSIS: Breast carcinoma and Port-A-Cath hematoma.
OPERATION: Evacuation of hematoma.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating room, and underwent general anesthesia with successful endotracheal intubation. The left chest was prepped and draped in the normal fashion. Time-out had been performed to identify correct patient and correct procedure. Incision was made over the previous port incision. Dissection was carried down through the skin and subcutaneous tissue. I felt the port. The patient was morbidly obese and I excised some chest wall fat. This created a hematoma in the area. This was a solid hematoma. With warm irrigation around a liter-and-a-half, this was evacuated as best as we could. There was noted to be excellent hemostasis. The port could be reached without problems. The skin was then closed with 3-0 nylon and the port was accessed easily and flushed with heparinized saline. A sterile dressing was placed. The patient tolerated the procedure well and was transferred to the recovery room in stable condition
PREOPERATIVE DIAGNOSIS: Breast carcinoma and Port-A-Cath hematoma.
POSTOPERATIVE DIAGNOSIS: Breast carcinoma and Port-A-Cath hematoma.
OPERATION: Evacuation of hematoma.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating room, and underwent general anesthesia with successful endotracheal intubation. The left chest was prepped and draped in the normal fashion. Time-out had been performed to identify correct patient and correct procedure. Incision was made over the previous port incision. Dissection was carried down through the skin and subcutaneous tissue. I felt the port. The patient was morbidly obese and I excised some chest wall fat. This created a hematoma in the area. This was a solid hematoma. With warm irrigation around a liter-and-a-half, this was evacuated as best as we could. There was noted to be excellent hemostasis. The port could be reached without problems. The skin was then closed with 3-0 nylon and the port was accessed easily and flushed with heparinized saline. A sterile dressing was placed. The patient tolerated the procedure well and was transferred to the recovery room in stable condition