Practice Charts for CPT and ICD code for Central line catheter placement


Sample Chart 1

NIVA BILATERAL LOWER EXTREMITY ANKLE ONLY:

INDICATION: Bilateral ankle ulcers.
TECHNIQUE: Bilateral brachial pressures and ankle segmental limb pressures, pulse volume recordings (PVRs), and ankle-brachial indices (ABIs) performed.

FINDINGS: PT ABI: RT: 1.18 LT: 1.16
PT Pressure: RT: 192 mmHg LT: 189 mmHg
DP ABI: RT: 1.17 LT: 1.12
DP Pressure: RT: 190 mmHg LT: 182 mmHg
Posterior tibial waveforms on the right are normal and markedly diminished on the left. Dorsalis pedis waveforms are also decreased in amplitude on the left. Pulse volume recordings at the ankle are relatively symmetrical and there is mild dampening of the great toe PPG on the right compared with the left.
IMPRESSION: 1. Diminished wave amplitude dorsalis pedis and posterior tibial arteries are continuous wave Doppler left side of uncertain clinical significance considering the normal ankle-brachial indices.

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CPT: 93923
Practice Sample charts in Medical coding



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Sample chart 2

ULTRASOUND-GUIDED RIGHT INTERNAL JUGULAR CENTRAL LINE PLACEMENT:

INDICATION/DIAGNOSIS: Septic emboli. Renal failure

POSTOPERATIVE DIAGNOSIS: Same

CONTRAST: 0 mL contrast

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CONSENT: The procedure, risks, indications and alternatives were explained. All questions were answered and informed consent was obtained, signed and witnessed from the mother by Dr. Warner
SEDATION: None.

TECHNIQUE: The procedure was performed using maximal sterile barrier technique including cap, mask, sterile gown, sterile glove, large sterile sheet, hand hygiene, and 2% chlorhexidine scrub for cutaneous antisepsis. The right neck was prepped and draped in the usual sterile fashion. Local anesthesia had been obtained and prior access to the internal jugular vein had been obtained for filter placement. The right internal jugular vein was accessed under direct ultrasound visualization with a micropuncture needle. A guidewire was advanced centrally. The tract was dilated. A 20 cm vas catheter was placed with the tip at the right atrial/superior vena caval junction. The catheter was flushed, sewn in place and is ready for immediate use. The patient tolerated the entire procedure well.
FINDINGS: Spot film was obtained documenting a smooth course with the tip at the right atrial/superior vena caval junction. No catheter kinking. No  definite evidence for pneumothorax.

FLUOROSCOPY TIME: 0.2 minutes of fluoroscopy time was used.

ESTIMATED BLOOD LOSS: Less than 10 mL

IMPRESSION: 1. Successful placement of a right internal jugular Vas Cath.

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