Michelle Posted Thu 04th of February, 2016 08:58:55 AM
Attached is an op report for a incarcerated umbilical hernia with the repair of a bowel perforation caused by the hernia. I coded the procedure as 49587, to me the bowel repair would be included. Is this true or am I over thinking this. Should I also charge a 44602? Any help with this would be greatly appreciated.
Incarcerated umbilical hernia.
Incarcerated umbilical hernia with small bowel perforation.
Repair of incarcerated umbilical hernia and repair of small-bowel perforation.
Incarcerated small bowel with some ischemic changes but no frank necrosis. Small area of perforation at the
level that the small bowel exited the fascia.
DESCRIPTION OF PROCEDURE:
Patient was brought to the OR table. She was placed in supine position. General anesthesia was induced. She
was prepped and draped in standard fashion. A transverse infraumbilical incision was made. This was carried
down through the subcutaneous tissue. The umbilical stalk was taken off the level of the fascia. The hernia sac
was dissected out circumferentially and hernia sac was then opened and the small bowel examined. We were unable
to further eviscerate the small bowel due to the small fascial defect. At that point the fascial defect was
enlarged by 1 cm medially. The small bowel was run, partially eviscerated and examined. The incarcerated small
bowel was purplish consistent with transient ischemia, but there was no frank necrosis. Once it had been
released from the fascia, it began to pink up. A small perforation was noted where the small bowel had
previously exited the fascia. This was repaired in 2 layers with 3-0 Vicryl suture. The small bowel was then
dunked back into the abdomen. The hernia sac was excised and the fascial defect was closed with several
interrupted #1 PDS sutures. The umbilical stalk was then tacked back down to the fascia. The subcutaneous
tissue was closed and the skin was closed with 4-0 Monocryl. Dressing was applied. Patient tolerated the
procedure well and was transferred to PACU after extubation.
SuperCoder Answered Fri 05th of February, 2016 00:43:35 AM
“AAE does not provide coding for operative reports and chart notes."
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information. ’