help with procedure

[jberg]

Can anyone help with this. It there a procedure for this or just do an E/M code

Using sterile technique and after cleansing the area with alcohol, marking the spot with a magnet, and then cleaning the area with Betadine, the needle was inserted in the central area perpendicular to the skin. We came into some resistance and Dr. ______was consulted and was kind enough to come in. He basically just pushed it right through that tissue until it hit the port. He withdrew some methylene blue fluid and then instilled 60 cc of sterile water. Patient stated she didn't even feel it. That actually felt better than when it was instilled initially, and she tolerated it very well. Band-aid applied after the needle was removed.

Thanks so much for any help provided.

 

[Alicia Scott]

I don't think there is enough information here to do any coding.

 

[jberg]

There was enough for an E/M code that I didn't add in here, I was just wondering if there is a procedure that would fit this description. I could not find anything.

 

[Laureen]

supply the entire redacted report and perhaps we can help figure it out. I don't even know what anatomical area is being worked on and there is mention of a port.

 

[jberg]

This is the majority of the office note. I have left off the meds, etc. I am thinking just a 99212.





______ comes in for the purpose of instilling fluid in her right breast expander. She has had no problems. Incision looks good. Video has been reviewed plus the manual information she brought along and the model of the expanders also noted.

PMH complete

Vitals Noted

Exam Only the general of well developed, no acute distress, Appears well nourished


Using sterile technique and after cleansing the area with alcohol, marking the spot with a magnet, and then cleaning the area with Betadine, the needle was inserted in the central area perpendicular to the skin. We came into some resistance and Dr. __________was consulted and was kind enough to come in. He basically just pushed it right through that tissue until it hit the port. He withdrew some methylene blue fluid and then instilled 60 cc of sterile water. Patient stated she didn't even feel it. That actually felt better than when it was instilled initially, and she tolerated it very well. Band-aid applied after the needle was removed.

PLAN: We will have her return in one week. She would like to try to get this done in three sessions. Initially 400 was put in and then another 50, for a total of 450. We put 60 cc in today, so we are up to 510 and it holds 600 or a little bit more. We will instill another 60 cc and see what it looks like. We want that a little bit larger than the left breast. There wasn't even any blanching of the skin, in other words it was not tense at all. The patient tolerated the procedure very well. She will return in another seven days for placement of another 60 cc.