Assign the appropriate Procedure Codes using ICD-10-PCS; and Start with the “Procedure…

Assign the appropriate Procedure Codes using ICD-10-PCS; and Start with the “Procedure Performed” header to know what to code. Don’t forget about the imaging codes! Patient Name: Victor Donnis DOB: 10-15-71 Sex: M Date of Admission: 06-25- XX Surgeon: Siobahn O’Malley, MD Pre-Operative Diagnosis: Metastatic colon cancer Post-Operative Diagnosis: Metastatic colon cancer Procedure Performed: Insertion of Infuse-A-Port Anesthesia: Moderate Sedation Complications: None Description of Procedure: After the risks, benefits, and alternatives to the procedure were discussed with the patient and the patient’s wife, informed written and verbal consent were obtained. The patient was brought to the angiography suite and placed on the procedure table in supine position. The right neck and anterior chest were prepped and draped using maximal sterile barrier technique. IV fentanyl and Versed were titrated for moderate sedation by trained interventional radiology nurse under my direct supervision for a 20- minute procedure. Ultrasound of the right neck shows patency of the right internal jugular vein with an ultrasound image saved to the PACS. The skin site was then infiltrated with 1% lidocaine for local anesthetic. Under live ultrasound guidance, the right internal jugular vein was cannulated with a 21-gauge micropuncture needle and via Seldinger technique, a short 5-French micropuncture sheath was placed. Next, the skin site inferior to the clavicle was infiltrated with 1% lidocaine with epinephrine for local anesthetic. A skin incision was made and the Mediport pocket was formed with blunt dissection. Next, the Mediport catheter was tunneled from the incision site through the subcutaneous tissues to the venotomy. The catheter length was tailored and then delivered through a peel-away sheath into the right atrium. The peel-away sheath and guidewire were both removed in their entirety. A hard copy fluoroscopic image of the chest shows smooth contour of the Mediport catheter, with the tip terminating at the superior cavoatrial junction. This fluoroscopic image was saved to the PACS. The catheter flushes and aspirates easily and was then packed, with heparin at 100 unit/mL. The Mediport pocket was closed with two, 3-0 Vicryl interrupted sutures and subsequently with running subcuticular stitch using 4-0 Vicryl. A single interrupted 3-0 Vicryl suture was placed at the venotomy. Dermabondwas applied along with Steri-Strips. Hemostasis, was therefore achieved. The patient tolerated the procedure well without complication and was transferred to recovery in fable condition.