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Joined: 19 Aug 2011
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PostPosted: Wed Dec 19, 2012 1:24 pm    Post subject: 49418 or 49419 Reply with quote

49418 or 49419 for the following dictation, I'm thinking 49419 - if so, can I then code conscious sedation 99144? Any and all help is greatly appreciated !

Abdomen Drainage W/ Tunneled Catheter

Indications: Abdominal distention and pain

Conscious sedation
Patient was given 1 mg of Versed and 50 mcg of fentanyl. Vital signs including artery, pulse oximetry and blood pressure were monitored continuously. Dr. XXXX was present and monitored throughout the procedure.

Abdomen Drainage W/ Tunneled Catheter
Appropriate entrance point was utilized by examining the abdomen with ultrasound. Folloowing this an appropriate entrance point was marked, cleaned and draped in the usual sterile fashion and infiltrated with 1% lidocaine. An 18 gauge trocar needle was advanced through a 3mm dermatotomy. Ascites fluid was noted. A superstiff wire was advanced. The tract was dilated to 14 French and a 14 French peel-away sheath was placed. Approximately 4 fingerbreadths below a subcutaneous tunnel was created with 1% lidocaine. An abdominal drainage catheter was connected to a trocar assembly which was advanced through this tunnel to the entrance point. The core and wire were removed, the catheter was advanced the peel-away sheath and the peel-away sheath was removed in it's entirety. The wounds were closed with interrupted 2-0 silk. Approximaelt 4 L of fluid was drained.

Conclusion: Successful placement of tunneled abdominal drainage catheter.

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