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drainage of presacral space

Heidi Posted Thu 18th of December, 2014 15:16:03 PM

Help with CPT code please!

DATE OF OPERATION/PROCEDURE: 10/28/2014

PREOPERATIVE DIAGNOSES
Colorectal anastomotic leak with presacral fluid collection proximal, stool
found in colon.

POSTOPERATIVE DIAGNOSES
Colorectal anastomotic leak with presacral fluid collection proximal, stool
found in colon.

OPERATION/PROCEDURE PERFORMED
Exam under anesthesia, drainage of presacral space, rigid proctoscopy with
irrigation and aspiration of distal colon, placed a transanal presacral drain.

OPERATIVE INDICATIONS

OPERATIVE FINDINGS
1. Contained presacral abscess with purulence.
2. No-to-minimal stool found in distal colon.
3. 2-inch Penrose drain placed in the presacral space and sutured to the
left anal margin with redundancy of the Penrose in the presacral space noted.

OPERATIVE PROCEDURE IN DETAIL
Patient was taken to the operating room, placed in supine position after
induction of general anesthesia, LMA was inserted. He was placed in lithotomy
position using candy-canes.

Digital rectal exam was performed which revealed the posterior 40% to 50%
circumference of the anastomosis about 3 cm above the dentate line to be
disrupted. There was a presacral collection of purulence. This was irrigated
and aspirated with no additional fluid encountered and anoscope was used to
help visualize this anastomotic disruption for irrigation and aspiration.

Rigid proctoscopy was then performed. The proximal colon was reached and
minimal stool was seen. The distal colon was irrigated and aspirated with
minimal effluent noted. The water was forced into the rectum by insufflating
the proctoscope after water was inserted into the proctoscope itself.

An anal tract was then placed. A 2-inch Penrose was placed in the presacral
space. It was then trimmed at the anal margin. It was then sutured to the
anal verge with 2-0 silk x2 after painting the area with Betadine.

At this point, the procedure was terminated. The area was then washed and
dried. A diaper was applied. The patient was then awoken from anesthesia. The
LMA was removed. He was then taken to recovery room in stable condition
having tolerated the procedure well.

SPECIMENS SUBMITTED
None.

COMPLICATIONS
None.

DRAINS
Penrose drain.

ESTIMATED BLOOD LOSS
Minimal.

IV FLUIDS
100 mL of crystalloid.

CONDITION/DISPOSITION UPON COMPLETION
Patient transferred to recovery room in stable condition.
REPORT IS PRELIMINARY UNLESS SIGNED

SuperCoder Answered Fri 19th of December, 2014 03:45:51 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 customerservice@supercoder.com for more information.

Thanks !!

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