# Exploratory Laparotomy Gunshot PLEASE HELP



## bill2doc (Dec 23, 2011)

Can anyone help with this one.  First time with this.  Thank you !

Gunshot wound to the right chest status post exploratory laparotomy and packing of the liver

1. exploratory laparotomy
2. removal of hemostatic packing
3. homostatic maneuvers on the liver
4. repair of diaphragmatic injury

Draped in standard fashion. previous incision opened and abdomen entered. Some bloody fluid intra abdominally most of which is old blood. 3 sponges previous placed were identified and removed. Still some bleeding from dome of liver where bullet wound had been. two areas of injuty to liver with both capsular adn parenchymal injury mostly on the upper right aspect including the dome.  The liver was mobilized forward and blood clots removed. A laser was used to seal the capsular injury. previous areas of mobilizaiton were examined. No evidence of bile leak and no acute bleeding, only weeping from wound edges.  The underside of liver where bullet entered examined with some capsular injury but hemostatic. Closed with laser.Surgicel and trombin w/gelfoam were placed in these previous bare areas to assure hemostasis.  Site of the bullet hole entry to liver identified as was hole in the diaphragm. Bullet hole to liver was assured to be hemostatic uning above maneuvers. The diaphragmatic injury was grasped on eiather edge with clamps and was noted to be approx 1 cm in width. Closed with silk suture.

Exam then turned to remainder of abdomen. Given the bullet track, the retroperitoneal area was examined. The retrop kidney was indenified but not completely dissected as there was no surrounding hematome and no evidence of ongoing bleeding. Right colon was mobilized medially completely. Remainder of ligamentous attachments that remained from previous procedure were freed as was the lateral aspect of teh duodenum in an extended Kocher maneuver. The vena cava was identified and noted to be free from injury. No ther areas bleeding noted. Bowel once again fun from the ligament of treitz to the ileocecal junction. colon examined from cecum to the pelvis. stomach was reexamined and noted free of injury. Abdomen was irrigated w/warm saline. abdomen was closed with suture. The skin was closed with staples. Dressings applied.


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## pkidd (Dec 23, 2011)

*GSW Ex/lap reply*

Greetings,

Thank you for posting the op note.

I would probably code this using CPT codes 47350 for repair of the liver lac and also 39501 for repair of the diaphragm.

There are no CCI edits with these codes and depending on the payer, I might use modifier 59 on the second code (39501).

I would definitely query the surgeon as to whether he/she considers this a simple or complex repair of the liver.   If it is a complex repair, the primary CPT code would be 47360.  The H&P/consult might give you a clue about simple vs complex repair.

Disclaimer: I don't tpically code extensive trauma.  You might try posting the question to The Coding Institute coding forum for general surgery.  There are some very good trauma coders who monitor that forum.

If you would like to contact me directly or have other questions, my e-mail is pkidd@samhealth.org

I hope this was helpful - good luck with the case!
Pat Kidd, CPC, CGSC


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## tcooper@tupelosurgery.com (Dec 28, 2011)

I would use 47361 and 39501. In your operative note it looks like he explored the wound and he did do coagulation with cautery. I don't know if you have Super Coder or not but when I pulled up this code it seemed to be the appropiate code to use. I would either use a 59 or a 51 modifier on code 39501 depending on carrier. I hope this helps.
Have a good day.
Teresa Cooper, CGSC


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