How you would know to assign qualifier of x for diagnostic


Problem

I. Determine what in the operative note documentation indicates to you that this bone marrow aspiration was performed with the approach percutaneous?

II. Identify how you would know to assign the qualifier of X for Diagnostic on this case.

III. The body part for this procedure would be Bone Marrow, Iliac. What is the specific documentation in the operative note that leads you to this body part

Preoperative Diagnosis: Hodgkins, nodular sclerosis
Postoperative Diagnosis: Same
Procedure: Bone Marrow aspiration

Procedure performed in OR under anesthesia. Patient identified and consent obtained. Bone marrow studies performed today as patient is having a mediport placed by general surgery during same operative session, dictated separately. 11-gauge Jamshidi biopsy needle used. Bone marrow biopsy sample obtained from right posterior iliac crest and sent to pathology. Tolerated procedure without complications and was handed to surgery team for placement port.

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Other Subject: How you would know to assign qualifier of x for diagnostic
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