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aspiration

Eunice Posted Thu 25th of April, 2013 15:33:45 PM

CLINICAL INFORMATION: For aspiration of right lateral postlumpectomy seroma and right axillary seroma.

FINDINGS: Aspiration procedure was performed under ultrasound guidance.

The previously visualized complex seroma in the lateral right breast is again appreciated. Aspiration was performed. 320 ml of serosanguineous fluid was aspirated. A 9.0 x 2.4 x 9.0 cm complex seroma remains.

The previously identified seroma in the right axilla was also aspirated to completion. 20 ml of serous fluid was aspirated.

IMPRESSION:
STATUS POST ASPIRATION OF RIGHT LATERAL POSTLUMPECTOMY SEROMA. 320 MM OF SEROSANGUINEOUS FLUID WAS ASPIRATED AND SENT FOR CULTURE AND SENSITIVITY. A 9 CM COMPLEX SEROMA REMAINS.

STATUS POST ASPIRATION OF A RIGHT AXILLARY SEROMA. 20 ML OF SEROUS FLUID ASPIRATED AND SENT FOR CULTURE AND SENSITIVITY. THE SEROMA WAS ASPIRATED TO COMPLETION.

Using CPT 76942, 19000 and icd9 998.13 would be correct for this report?

Thank you!

SuperCoder Answered Thu 25th of April, 2013 22:01:00 PM

Please contact Manney at 866-228-9252 Extn : 4165 customer service.

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