# Need guidance - exploratory laparotomy with evacuation of hematoma, bleeding control



## jocarter (May 22, 2018)

New to coding for surgery and totally lost on this one:  I am interpreting this a 2 separate procedures- first re-opening the pfannenstiel incision and removing the hematoma I was thinking 35840 for that portion, but further down it reads that they made a completely separate incision where blood clots where removed along with bleeding control of the falciform ligament (this is where I am totally lost and need direction- thinking it would be a 49000, but because he did bleeding control and evacuation of blood clots I can not find an "open" procedure for that and the 49000 somehow doesn't seem right since we did more than just look inside....) Hope my rambling make sense!  Any recommendations would be greatly appreciated.  Right now I am leaning towards an unlisted code.


Preoperative diagnosis: Intra-abdominal bleeding
Postoperative diagnosis: Intra-abdominal bleeding with cirrhosis and portal hypertension
Procedure: Exploratory laparotomy, evacuation of hematoma and control of bleeding 
Surgeon: XXX 
Asst.: XXX
Anesthesia: General
Findings: 5000 mL of intra-abdominal blood noted. Evidence of cirrhosis and portal hypertension. 2 lap packs were left in the abdomen, one anterior to the uterus and the other posterior in the pelvis.

Indications for surgery: Persistent bleeding and increasing abdominal distention with coagulopathy

Operative summary: Patient had undergone C-section for placenta previa earlier the same day. Postoperatively she experienced hemorrhage and persistent bleeding despite massive blood transfusion and resuscitation. I been asked to see for possible surgery and was concerned about DIC. I also asked by partner Dr. XXX for his opinion and he recommended proceeding to the operating room. After consent had been obtained from the patient's husband the patient was brought to the operating room and placed in the operating table in supine position. The patient had been previously intubated prior to transfer to the operating room. A timeout procedure was held and Invanz was given preoperatively.

The previous Pfannenstiel incision was opened with the scalpel and sutures were removed down to the level of the fascial incision. Large hematoma was noted in the tissue and small areas of bleeding were present. Hematoma was evacuated and the small bleeding areas were cauterized.

Our attention was then directed to the midline where an incision was made and carried down through the subcutaneous tissue with cautery unit. Note was made of a large amount of bruising in the subcutaneous tissue itself. There is also a quite a bit of edema fluid as well. The fascia was then incised and the abdomen was entered bluntly with a hemostat. Incision was then extended through the fascia to the length of the skin incision. On entering the abdomen large amount of clot was noted. These blood clots were evacuated and the abdomen was inspected. The spleen appeared to be intact with no evidence of bleeding from the left upper quadrant. The liver was palpated and noted to be cirrhotic. We also had bleeding from dilated veins from the falciform ligament which were controlled with hemostats and silk ties. After most of the blood clots were removed manually, the abdomen was then irrigated. Approximately 5000 mL of blood was evacuated prior to irrigation.

After irrigation related been performed, there is no evidence of major bleeding coming from the upper abdomen. Inspection of the uterus is noted to have a bogginess to. There was some oozing along the periuterine area between the uterus and the bladder. However no active arterial bleeding was noted. After the area was carefully inspected and all blood clots of been evacuated, Arista powder was placed in this area and a lap pad was placed and packed in this area. A 2nd lap pad was placed posteriorly into the pelvis as well. An Apthera wound VAC dressing was placed over both the Pfannenstiel incision and our midline incision. The 2 were then connected to the same suction via bridge. Minimal bleeding was noted from the Pfannenstiel incision.


Thank you.


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## Babsss (May 28, 2018)

I agree with 35840 with a 78 modifier.  I believe this is your best code.  The RVU's are 34.71 which covers the work involved.


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