Stephanie Posted Wed 27th of March, 2019 12:31:06 PM
Good morning, my provider performed the following procedure I'm leaning towards unlisted code 49329, but I'm not sure what code to liken this procedure too. Here's the information from the op note: Findings: She had clotted and liquid old blood in the abdomen, which we irrigated out. There was no evidence of any active bleeding.
However, on the greater curvature of the stomach, there was an obvious
hematoma about a third of the way down the fundus. This was within the
arcade of vessels proceeding to the omentum. We opened this area and
mobilized the greater curvature, so that we could see into the lesser
sac as well. There was no active bleeding there. The spleen looked
okay. We went ahead and divided this segment of arcade vessels using the
LigaSure, thereby sealing them about a centimeter from the greater
curvature of the stomach, especially in the area where the bleeding had
occurred. There was no active bleeding during the operation or thereafter.
ESTIMATED BLOOD LOSS FROM SURGERY: Less than 5 mL.
WOUND CLASS: I.
DESCRIPTION OF PROCEDURE: The patient received Ancef intravenously
preoperatively. She was given a general endotracheal anesthetic and
prepped and draped in a supine position.
After successful timeout, pneumoperitoneum was obtained with a Veress
needle in the right upper quadrant. There was no bleeding or injury at
A 5 mm port was placed just to the right and above the umbilicus.
Through that port, we observed the abdominal cavity. There were no
adhesions, but there was old blood.
We placed a total of four 5 mm ports in the right upper quadrant, left
upper quadrant and left lower quadrant as we progressed through our
Findings were as described above. After sufficient irrigation, we went
ahead and used a LigaSure through one of the 5 mm ports to open up into
the lesser sac. We divided about 3 or 4 vessels going to the omentum,
including the one that had a hematoma around it. We sealed this along
the edge of the stomach, staying about a centimeter away from the
There was no active bleeding. We suctioned out clot. There were a few
pieces of omentum that we placed into a 5 mm bag and removed through one
of the port sites.
We irrigated again and irrigated most all of the blood that we could
see. There was still some very dilute blood stained irrigation left behind.
Pneumoperitoneum was evacuated and the ports were removed. The skin was
closed at each port site with subcuticular sutures and Steri-Strips.
SuperCoder Answered Thu 28th of March, 2019 04:39:21 AM
Your coding seems appropriate. You should use CPT code 35840 (Exploration for postoperative hemorrhage, thrombosis or infection; abdomen) as a comparison code.
Note: When submitting an unlisted-procedure code, your documentation should also include an explanatory cover letter. An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.