can I please get help with finding codes for these cases

OPSX31MayweatherCora

MCCG240 Case Scenario OPSX31 Mayweather, Cora.html[10/21/2021 10:55:48 AM]

Outpatient Surgery

Patient Case Number: OPSX31-Mayweather, Cora

Patient Name: Cora Mayweather DOB: 03-01-66 Sex: F

Date of Service: 08-13-XX Surgeon: Matthew Bordelon, MD

Pre-Operative Diagnosis Metastatic stage IIIC cancer of ovary w/ involvement of the rectosigmoid colon and ovaries

Post-Operative Diagnosis Metastatic stage IIIC cancer of ovary w/ involvement of the rectosigmoid colon and ovaries

Procedure Performed: Insertion of single-lumen infusaport, debridement of necrotic tissue around stoma, removal of PICC line

Anesthesia: General Complications: None

PREOPERATIVE DIAGNOSES: 1. Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and the cul-de-sac, status post ovarian cancer debulking. 2. Lack of vascular access.

POSTOPERATIVE DIAGNOSES: 1. Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and the cul-de-sac, status post ovarian cancer debulking. 2. Lack of vascular access.

OPERATIVE PROCEDURE CARRIED OUT: 1. Insertion of a single-lumen infusaport. 2. Debridement of necrotic tissue around the stoma. 3. Removal of PICC line.

DESCRIPTION OF PROCEDURE: After successful induction of general anesthesia, the patient was placed in steep Trendelenburg position. The neck and the chest wall was prepped and draped in the usual sterile fashion. An infraclavicular subclavian puncture was then made. Guidewire was inserted into the right atrium. The needle was then removed. The position of the guidewire was tested radiographically. A dilator introducer kit was inserted over the guidewire into the right atrium. The right guidewire was removed. The catheter was inserted into the right atrium under fluoroscopic guidance. A transverse incision was then made on the anterior chest wall. Subcutaneous tissue was incised along the line of the incision. The catheter was tunneled subcutaneously to the point on the anterior chest wall. The catheter was connected to the reservoir such that the tip of the catheter was located in the right atrium. The catheter was then attached to the

OPSX31MayweatherCora

MCCG240 Case Scenario OPSX31 Mayweather, Cora.html[10/21/2021 10:55:48 AM]

reservoir. The reservoir was then flushed. The reservoir was sutured to the anterior chest wall. The patient tolerated the procedure well. The skin was closed with subcuticular suture. The skin was closed with subcuticular sutures. The patient tolerated the procedure well. The patient was transferred to the recovery room under satisfactory conditions. The PICC line was removed by gentle traction. The tip of the catheter was intact. A sterile dressing was applied on the right arm where the PICC line has been taken out. The ostomy in the left lower quadrant was revisualized. The tissue around the colostomy was excised. A new colostomy bag was then placed over this site. Minimal debridement of necrotic tissue around the base of the stoma was carried out and by sharp dissection.

Dictating Clinician: Matthew Bordelon, MD

Electronically Signed By: Matthew Bordelon, MD

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