We had a patient with a Umbilicus cyst. The provider used a ligation technique and I'm having trouble finding a way to code it. Here is his note:
Umbilicus was thoroughly cleansed with Hibiclens swabs and gauze. Using aseptic technique, abdominal pressure and lifting with a swab the cyst was exposed, and a surgical knot loop of 4-0 nylon suture was placed over base. This was then carefully tightened so that cyst was ligated at the base. Infant had some initial discomfort which quickly resolved. ligation was tied off and trimmed to have ends exposed to skin. Discussed aftercare instructions with mother. Child breast fed after procedure, and after 5 minutes area was not shown to have bleeding or swelling.
Wondering if there is a way to charge this or is it included in the E&M. Any help is appreciated, thanks!
Umbilicus was thoroughly cleansed with Hibiclens swabs and gauze. Using aseptic technique, abdominal pressure and lifting with a swab the cyst was exposed, and a surgical knot loop of 4-0 nylon suture was placed over base. This was then carefully tightened so that cyst was ligated at the base. Infant had some initial discomfort which quickly resolved. ligation was tied off and trimmed to have ends exposed to skin. Discussed aftercare instructions with mother. Child breast fed after procedure, and after 5 minutes area was not shown to have bleeding or swelling.
Wondering if there is a way to charge this or is it included in the E&M. Any help is appreciated, thanks!