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Ob-Gyn Coding Alert

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Try Your Hand at This Adhesions Lysis, Appendectomy Scenario

Published on Wed Sep 16, 2009

Question: My ob-gyn documented the following op note: "Omental adhesions made visualization of the pelvis difficult. These were covering the fundus of the uterus and anterior parietal peritoneal surface. Also, they completely obliterated the cul-de-sac. I found chronic and acute pelvic inflammatory disease as well as pelvic abscesses. Due to the large amount of adhesions, I spent a lot of time visualizing and freeing the fundus of the uterus, left adnexa, left tube and ovary, right adnexa structures, right tube and ovary, posterior cul-de-sac, and the sigmoid bowel. I lysed loops of bowel, and I removed the appendix. I exposed additional adhesions of the sigmoid bowel to the right cul-de-sac and lower pelvis as well as a large abscess, right of the sigmoid bowel. I placed a Jackson-Pratt drain to drain the pelvis." What CPT codes are correct? Should I use modifier 22 on the laparoscopic appendectomy, or is the [...]
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