Lynn Posted Wed 22nd of February, 2017 07:15:37 AM
1. Operative laparoscopy with resection of right retroperitoneal mass.
2. Complete right ureterolysis for resection of adherent mass.
3. Extensive lysis of adhesions.
4. Laparoscopic repair of seromuscular tear with suture and intracorporeal knots.
Path says borderline tumor? 58660 ?
SuperCoder Answered Thu 23rd of February, 2017 03:17:33 AM
Please send some more details of the case for us to provide the correct code. Thank you.
Lynn Posted Fri 24th of February, 2017 09:58:21 AM
. Basler was brought to the operating room with an IV in place and anesthetic was administered. She was examined, prepped, and draped in the low anterior lithotomy position using PatientGuard stirrups. Arms were carefully padded with soft foam and tucked with care to avoid neuropathy. Shoulders were immobilized with the TrenGuard device. After draping was complete, a sponge stick was placed in the vagina. Insufflation was carried out with a Veress needle through a small incision at the base of the umbilicus after infiltrating with Marcaine. A 5 millimeter camera port was inserted. She was found to have numerous loops of small bowel adherent to the anterior abdominal wall in the lower midline parts of the abdomen at the site of previous vertical peritoneal incision (her skin and fascial incision were by Pfannenstiel approach). The lateral ports were able to be placed under laparoscopic guidance after infiltrating skin with Marcaine. This included one 5 millimeter port in the right lower quadrant and one in the left lower quadrant, followed by a second 5 millimeter port in the right lower quadrant. Laparoscopic scissors were used to carefully take down the adhesions. There was one area with a small seromuscular nick in the small bowel, but no evidence of any mucosal injury. This area was later repaired. The adhesions were fully taken down, after which the 12 millimeter suprapubic port was placed under laparoscopic guidance. Washings were obtained. The bowel adhesions overlying the mass were taken down using sharp dissection. The retroperitoneal space was opened and the mass was reflected medially. Attachments to the ureter were carefully taken down after identifying the vessels and ureter. The vessel was well clear of the mass, but ureter was densely adherent. Ureter was therefore tunneled along the path of the pelvis using sharp dissection and electrosurgery with complete ureterolysis from the pelvic brim to the bladder. Once the ureter was adequately mobilized, surrounding attachments were sealed and divided with the LigaSure. Mass was placed into the specimen retrieval bag intact and was decompressed in situ. Mass was removed and submitted for permanent histology. There was no evidence of residual neoplasm and the remainder of the survey of the abdomen including all peritoneal surfaces of small and large bowel, liver, diaphragm, and upper abdominal structures was unremarkable. The bowel was inspected at the site where there was a small seromuscular nick had previously been made, and this area was oversewn with 3 laparoscopically placed Lembert stitches using 3-0 Vicryl. Sutures were placed laparoscopically and tied intracorporeally. There were no other signs of any seromuscular problems and the abdomen was then irrigated. Low-pressure check was carried out and excellent hemostasis was noted. The 12 millimeter port was removed and closed with laparoscopic guidance using the Endoclose needle. The pneumoperitoneum was released and ports were removed. Skin was closed with inverted interrupted subcuticular stitches using 4-0 Monocryl. Final sponge, needle, and instrument counts were correct at the completion of the procedure. Ms. Basler was awakened and taken to postanesthesia care unit in stable condition.
SuperCoder Answered Mon 27th of February, 2017 04:14:10 AM
Hi, as per documentation, code 58660 should be appropriate. Also, please check your payer preference for the same. Thank you.