Central line insertion Preoperative Diagnosis: Colon/ Rectum

Central line insertion Preoperative Diagnosis: Colon/ Rectum and Sigmoid flexure Cancer, ICD-10-CM code: 1)___________________________ 2)___________________________ Postoperative diagnosis: same A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient is a 40-year-old with colon malignancy, he presents today for chemo line insertion. They were placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen 9-French Cords catheter was introduced into the internal jugular using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Dr. Bombay was present for the entire procedure. Ultrasound imaging showed the catheter tip was in the SC. Patient tolerated procedure well. Procedure Note: Central line insertion, ICD-10-PCS code 1:_______________________ , US Guidance 2:______________

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