Tammy Posted Tue 05th of January, 2016 10:53:12 AM
the Procedure states:
Minilaparotomy and salpingostomy and evacuation of products of conception.Primary repair of salpingostomy.
but on the Operation report:
The trocars were removed and the abdomen was entered by means of a small transverse incision in the lower abdomen which was carried to the fascial plane. The fascia was then transversely incised. The underlying rectus muscle was stripped away by blunt and sharp dissection. The peritoneum was vertically entered through a muscle-splitting Pfannenstiel technique.
I am thinking this was converted to an open procedure:
making this a 59120 what are your thoughts? please let me know. thanks much!!
SuperCoder Answered Wed 06th of January, 2016 07:29:16 AM
In order to code for this procedure, you need to clarify with the surgeon whether the technique was open. As in this case it is determined by the size of the incision given. The Pfannenstiel technique mentioned appears to be an open technique but we cannot code it for open procedure unless and until surgeon confirms it. So, please go through the report ans clarify with the surgeon for the technique used.