Jennifer Posted Mon 09th of February, 2015 19:08:48 PM
I need help coding this procedure. I am thinking 51590 with mod 22 and 50605 for the stent but not sure if I covered everything that was performed by my doctor. Thank you. The op report states:
The patient was taken to the operating room, and placed in a supine position. The abdomen was prepped and draped in a sterile fashion. A midline abdominal incision was made over the prior incision site. The incision was carried down through the fascia and the peritoneal cavity was entered. Multiple adhesions were noted. The bowel was attached to the anterior abdominal wall. The adhesions were carefully taken down and the bowel segments were isolated. The ileal chimney was identified and isolated with a Penrose drain. Care was taken to preserve the mesentery supplying the ileal segment. The bowel was markedly distended due to the patient's ileus. In particular, the sigmoid
colon was very distended and was packed underneath the upper portion of the abdominal wall in order to allow for exposure to the retroperitoneum. The line of Toldt was identified by reflecting bowel contents medially.
The retroperitoneal space was entered and the ureter was identified. The ureter was freed proximally to the upper third of the ureter, taking care to preserve vascular supply around this structure. The distal end of the ureter was tagged and then cut at the level of its entry into the bladder. The ureter was then passed through the base of the sigmoid mesentery, taking care to prevent kinking or acute angulation of the ureter as it passed over to the
right side. The ureter was left tagged and then attention was directed
towards identification of the right ureter. This was identified, clipped and mobilized in a similar fashion. Next, a GIA stapler was used to transect the distal end of the ileal chimney from its attachment to the bladder. The distal end of the ileal segment was quite mobile and could be mobilized into the deep intraperitoneal space in close proximity to both of the ureters. Two openings were made at the butt ends of the ileal conduit. The mucosa was
everted using 4-0 Vicryl suture. The ureters were then spatulated and sewn to these openings in the ileal conduit using interrupted 4-0 Vicryl sutures. The anastomosis was completed over a single-J stent that was advanced through the ostomy out through the opening in the ileal conduit and then up the ureter. Clear urine could be seen coming from both of the ureteral stents indicating correct placement. Once the anastomosis was complete, the bowel was packed away cephalad and the lateral vascular pedicle supplying the bladder were cauterized and divided using the ligature. The pedicles were transected in a caudal direction and any bleeding sites were identified and secured with 0
silk ties. The posterior aspect of the bladder could be easily palpated, and the rectum was protected using a sterile towel and reflecting the posterior wall of the bladder anteriorly. Once both sides of the bladder had been dissected down to the level of the bladder neck and the bladder was freely mobile up to its attachment to the base of the prostate, the bladder was transected leaving a small segment of trigonal mucosa. This mucosa was extensively cauterized using the Bovie, and then oversewn using 2-0 chromic sutures. The pelvic cavity was copiously irrigated with sterile saline. There was no active bleeding noted. A Jackson-Pratt drain was placed in the
right lower quadrant. The fascia was closed with interrupted #1 Vicryl
sutures. The skin layers were reapproximated with skin staples. A stoma
appliance was applied, and a sterile dressing was applied as well. The
patient was transferred to recovery room in stable condition
SuperCoder Answered Tue 10th of February, 2015 04:08:57 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.