suela923@aol.com
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Ugh! I need help on this please!!!
We had a patient that was in one day for an evaluation of her seroma drainage tube under ultrasound and then was in two days later to have the drainage catheter removed, again under ultrasound. What codes would you use? THANKS!
Evaluation of seroma drainage tube DOS 02/12/14
Timeout procedure was performed. She was prepped and draped in the usual sterile fashion. Ultrasound examination of the drained fluid collections in her medial thigh showed a significant interval reduction in size of both major collections. The upper collection contains the upper loop of the drainage tube. Small residual collection is present. The distal collection is loculated and is significantly smaller than had been seen last week. Contrast was injected through this tube and showed 2 significantly smaller but loculated collections.
2 mg of TPA were again injected into the collections. They were allowed to dwell for one hour and then were aspirated.
She tolerated the procedure well.
Result Impression
The collections in the medial aspect of the thigh have significantly decreased in size with only small residual collections remaining at the upper and lower aspects of the tube as described. She is scheduled to return next week for further evaluation of her tube. I have instructed her to decrease her daily flushes to 5 cc but to continue to aspirate as much as possible from the tube. Hopefully the collections will have resolved on her next visit and we can remove the tube at that time. We have given her an additional prescription for antibiotics to give her adequate coverage while her drainage catheter is in place.
Ultrasound evaluation right thigh with percutaneous drainage catheter removal, DOS 02/14/14
History: Seroma right side following surgery. Recent percutaneous drainage catheter placement and TPA administration. Diminished output, blood-tinged.
Findings: Limited right medial thigh ultrasound was performed at and above the knee to the mid thigh. This shows catheter within a largely collapsed cavity. Although the output is now blood-tinged is not frankly bloody and is not suggestive of active bleeding. No new fluid collections are demonstrated. Patient reports that the swelling has diminished greatly without palpable collection. Percutaneous catheter was cut and removed without difficulty. Pressure dressing was applied. Patient was instructed on wearing and Ace bandage wrap during the day but not at night.
Result Impression
Minimal residual cavity with percutaneous drain in satisfactory position. Clinically improved. Diminished output. Drain was removed.
We had a patient that was in one day for an evaluation of her seroma drainage tube under ultrasound and then was in two days later to have the drainage catheter removed, again under ultrasound. What codes would you use? THANKS!
Evaluation of seroma drainage tube DOS 02/12/14
Timeout procedure was performed. She was prepped and draped in the usual sterile fashion. Ultrasound examination of the drained fluid collections in her medial thigh showed a significant interval reduction in size of both major collections. The upper collection contains the upper loop of the drainage tube. Small residual collection is present. The distal collection is loculated and is significantly smaller than had been seen last week. Contrast was injected through this tube and showed 2 significantly smaller but loculated collections.
2 mg of TPA were again injected into the collections. They were allowed to dwell for one hour and then were aspirated.
She tolerated the procedure well.
Result Impression
The collections in the medial aspect of the thigh have significantly decreased in size with only small residual collections remaining at the upper and lower aspects of the tube as described. She is scheduled to return next week for further evaluation of her tube. I have instructed her to decrease her daily flushes to 5 cc but to continue to aspirate as much as possible from the tube. Hopefully the collections will have resolved on her next visit and we can remove the tube at that time. We have given her an additional prescription for antibiotics to give her adequate coverage while her drainage catheter is in place.
Ultrasound evaluation right thigh with percutaneous drainage catheter removal, DOS 02/14/14
History: Seroma right side following surgery. Recent percutaneous drainage catheter placement and TPA administration. Diminished output, blood-tinged.
Findings: Limited right medial thigh ultrasound was performed at and above the knee to the mid thigh. This shows catheter within a largely collapsed cavity. Although the output is now blood-tinged is not frankly bloody and is not suggestive of active bleeding. No new fluid collections are demonstrated. Patient reports that the swelling has diminished greatly without palpable collection. Percutaneous catheter was cut and removed without difficulty. Pressure dressing was applied. Patient was instructed on wearing and Ace bandage wrap during the day but not at night.
Result Impression
Minimal residual cavity with percutaneous drain in satisfactory position. Clinically improved. Diminished output. Drain was removed.