How to code the below procedure?Can we code it as an E/M code
Procedure: Thrombin/Gelfoam slurry injection through subcutaneous
tunnel of indwelling right chest wall tunnel dialysis catheter.
The patient is status post
tunnel dialysis catheter exchange. The patient
returns with persistent and intermittent oozing from the
subcutaneous tunnel. Referred for catheter evaluation for
persistent oozing.
On physical examination, no active bleeding through the
subcutaneous tunnel is visualized, however, there is a small
amount of subcutaneous hematoma with expression of blood clot.
The right chest subcutaneous tunnel site was then prepped and
draped in usual sterile fashion. The skin and subcutaneous
tissues were anesthetized with 2% lidocaine solution. Injection
of a slurry composed of 5000 units of thrombin, normal saline
solution, and Gelfoam pledgets into the subcutaneous tunnel was
then performed. Injection was performed while simultaneously
compressing the right internal jugular vein. The skin entry site
was covered with a sterile dressing. The patient tolerated the
procedure well and left the department in stable condition.
Impression: Thrombin/Gelfoam slurry injection into subcutaneous
tunnel of indwelling right chest wall tunneled dialysis catheter,
as above.
Procedure: Thrombin/Gelfoam slurry injection through subcutaneous
tunnel of indwelling right chest wall tunnel dialysis catheter.
The patient is status post
tunnel dialysis catheter exchange. The patient
returns with persistent and intermittent oozing from the
subcutaneous tunnel. Referred for catheter evaluation for
persistent oozing.
On physical examination, no active bleeding through the
subcutaneous tunnel is visualized, however, there is a small
amount of subcutaneous hematoma with expression of blood clot.
The right chest subcutaneous tunnel site was then prepped and
draped in usual sterile fashion. The skin and subcutaneous
tissues were anesthetized with 2% lidocaine solution. Injection
of a slurry composed of 5000 units of thrombin, normal saline
solution, and Gelfoam pledgets into the subcutaneous tunnel was
then performed. Injection was performed while simultaneously
compressing the right internal jugular vein. The skin entry site
was covered with a sterile dressing. The patient tolerated the
procedure well and left the department in stable condition.
Impression: Thrombin/Gelfoam slurry injection into subcutaneous
tunnel of indwelling right chest wall tunneled dialysis catheter,
as above.