KBean2018
Guru
Hello, Can someone assist me in finding the correct codes for the below aborted procedure?
Procedure(s):
ABDOMINOPERINEAL RESECTION; ABORTED
VASCULAR CLIP LIGATION LEFT INTERNAL ILIAC VEIN Procedure Note
Pre-op Diagnosis: RECTAL CANCER
Post-op Diagnosis: Hemorrhage from left Internal Iliac Vein
CPT Code: Procedures:
* ABDOMINOPERINEAL RESECTION; ABORTED
* VASCULAR CLIP LIGATION LEFT INTERNAL ILIAC VEIN.
Findings: Omental adhesions to the upper abdomen. Descending colon adhesions to the anterior peritoneum. Redundant rectosigmoid without peritoneal ascites or implants. The sigmoid mesentery is released over the left pelvic inlet, the right perirectal space open, the cul-de-sac posterior to uterus is opened. In dissecting the left pararectal space, bleeding from the recognized left internal iliac vein, low pressure high flow controlled with pressure but exposure is difficult with severe pelvic obesity and clips are placed with poor visualization and some removed and replaced. Poor control of bleeding but controllable with pressure. Then, exposures difficult. The pelvis is packed after 1 L blood loss and volume resuscitation initiated, borderline hypotension, no tachycardia, hemoglobin dropping from 14 g/dL to 10 g/dL. Additional monitoring lines placed including arterial catheter. A second attempt at control with about 500 mL blood loss pressure held until a third attempt with 500 mL blood loss, the visualized laceration of the vein controlled with a series of 4 parallel placed medium clips. Intraoperative hemoglobin 8.8 g/dL, blood pressure 115/80, heart rate 100, base deficit -4. Decision was made to abort, no further dissection, no bowel is entered. A rolled Gelfoam is applied over the vein for compression, and then covered with 2 mL thrombin once no continued bleeding has been assured. Retractors are released, the redundant rectosigmoid fills the pelvis. In the absence of bleeding the incision is closed
Indications: She is a very low anterior rectal cancer, endoscopic staging T2N0 declining an opportunity for neoadjuvant chemoradiation therapy and attempt at transanal excision, requesting abdominal-perineal resection.
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. Foley catheter was placed and she is placed into a padded stirrups. The rectum was irrigated with Betadine, the tumor is hemi-circumferential beginning almost at the dentate line anteriorly and extending only about 2 cm cephalad. Nasogastric tube is placed, the abdomen is widely prepped with chlorhexidine, the perineum has been prepped with Betadine. Drapes are applied, the abdomen was entered through an infraumbilical midline incision, the adipose tissue about 4 or 5 inches deep to incise the fascia and into the abdomen. A Balfour retractor was placed and then incision is extended more cephalad for exposure. The bladder blade is introduced over a moist blue towel holding the small bowel cephalad. It is very difficult to exposed, one hand can elevate the descending colon, the other dissects the paracolic gutter over the left sacral promontory. Underscore the lateral perirectal peritoneum, and then on the right side. With a Harrington retractor elevating the posterior uterus, an incision in the peritoneum. I begin the pelvic dissection on the left side using cautery and then under visual the left pararectal space. Without identifying the left internal iliac vein, there is rapid bleeding from here controlled with side pressure. With difficult exposure, I recognize the left ureter and can palpate the pulsatile internal iliac artery. As I elevate the artery to expose the vein, there is bleeding. This is a cat and mouse endeavor where exposure to control results in more bleeding but pressure can easily be held to tamponade. I use 2 smaller clips and these are not accurately placed and are removed. Every time I look there is more bleeding. I placed a larger clips in the same thing happens. At 1 L, I hold pressure and then pack with a single Ray-Tec for pressure, and then this is removed and no additional Raytek are used. I placed additional clips but these are not accurate, and then these are removed. Pressure was held, and then finally with a automatic stapler, medium size, for parallel are placed in cover the visualized open venotomy. I then place a first, and then second and third rolled Gelfoam and the anesthesia service places additional line volume. She did not become hypotensive or excessively tachycardic, and we watched for about 30 minutes without additional active bleeding, I now sprayed 2 mL of thrombin over the area and having spoken with the family with advice to abort, the procedure was terminated. All laparotomy pads were removed and accounted for, the retractors were removed. The blue towel is removed. The small bowel lays on top of the rectosigmoid. The omentum is stuck in the upper abdomen and not mobilized. The NG tube was palpated in the high proximal stomach. With no active bleeding, the midline incision is closed with #1 Maxon suture anchored above and below and tied centrally. The soft tissue is cleaned, skin closed with staples and a CoverDerm. She had received muscle relaxants with her epidural, not breathing on her own and will be taken directly to the ICU on the ventilator without pressors.
I am reviewing an aborted(modifier 52) procedure. I’ve been reviewing 45110,45111,45112,45119,45121 codes, and 37660 for ligation
Procedure(s):
ABDOMINOPERINEAL RESECTION; ABORTED
VASCULAR CLIP LIGATION LEFT INTERNAL ILIAC VEIN Procedure Note
Pre-op Diagnosis: RECTAL CANCER
Post-op Diagnosis: Hemorrhage from left Internal Iliac Vein
CPT Code: Procedures:
* ABDOMINOPERINEAL RESECTION; ABORTED
* VASCULAR CLIP LIGATION LEFT INTERNAL ILIAC VEIN.
Findings: Omental adhesions to the upper abdomen. Descending colon adhesions to the anterior peritoneum. Redundant rectosigmoid without peritoneal ascites or implants. The sigmoid mesentery is released over the left pelvic inlet, the right perirectal space open, the cul-de-sac posterior to uterus is opened. In dissecting the left pararectal space, bleeding from the recognized left internal iliac vein, low pressure high flow controlled with pressure but exposure is difficult with severe pelvic obesity and clips are placed with poor visualization and some removed and replaced. Poor control of bleeding but controllable with pressure. Then, exposures difficult. The pelvis is packed after 1 L blood loss and volume resuscitation initiated, borderline hypotension, no tachycardia, hemoglobin dropping from 14 g/dL to 10 g/dL. Additional monitoring lines placed including arterial catheter. A second attempt at control with about 500 mL blood loss pressure held until a third attempt with 500 mL blood loss, the visualized laceration of the vein controlled with a series of 4 parallel placed medium clips. Intraoperative hemoglobin 8.8 g/dL, blood pressure 115/80, heart rate 100, base deficit -4. Decision was made to abort, no further dissection, no bowel is entered. A rolled Gelfoam is applied over the vein for compression, and then covered with 2 mL thrombin once no continued bleeding has been assured. Retractors are released, the redundant rectosigmoid fills the pelvis. In the absence of bleeding the incision is closed
Indications: She is a very low anterior rectal cancer, endoscopic staging T2N0 declining an opportunity for neoadjuvant chemoradiation therapy and attempt at transanal excision, requesting abdominal-perineal resection.
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. Foley catheter was placed and she is placed into a padded stirrups. The rectum was irrigated with Betadine, the tumor is hemi-circumferential beginning almost at the dentate line anteriorly and extending only about 2 cm cephalad. Nasogastric tube is placed, the abdomen is widely prepped with chlorhexidine, the perineum has been prepped with Betadine. Drapes are applied, the abdomen was entered through an infraumbilical midline incision, the adipose tissue about 4 or 5 inches deep to incise the fascia and into the abdomen. A Balfour retractor was placed and then incision is extended more cephalad for exposure. The bladder blade is introduced over a moist blue towel holding the small bowel cephalad. It is very difficult to exposed, one hand can elevate the descending colon, the other dissects the paracolic gutter over the left sacral promontory. Underscore the lateral perirectal peritoneum, and then on the right side. With a Harrington retractor elevating the posterior uterus, an incision in the peritoneum. I begin the pelvic dissection on the left side using cautery and then under visual the left pararectal space. Without identifying the left internal iliac vein, there is rapid bleeding from here controlled with side pressure. With difficult exposure, I recognize the left ureter and can palpate the pulsatile internal iliac artery. As I elevate the artery to expose the vein, there is bleeding. This is a cat and mouse endeavor where exposure to control results in more bleeding but pressure can easily be held to tamponade. I use 2 smaller clips and these are not accurately placed and are removed. Every time I look there is more bleeding. I placed a larger clips in the same thing happens. At 1 L, I hold pressure and then pack with a single Ray-Tec for pressure, and then this is removed and no additional Raytek are used. I placed additional clips but these are not accurate, and then these are removed. Pressure was held, and then finally with a automatic stapler, medium size, for parallel are placed in cover the visualized open venotomy. I then place a first, and then second and third rolled Gelfoam and the anesthesia service places additional line volume. She did not become hypotensive or excessively tachycardic, and we watched for about 30 minutes without additional active bleeding, I now sprayed 2 mL of thrombin over the area and having spoken with the family with advice to abort, the procedure was terminated. All laparotomy pads were removed and accounted for, the retractors were removed. The blue towel is removed. The small bowel lays on top of the rectosigmoid. The omentum is stuck in the upper abdomen and not mobilized. The NG tube was palpated in the high proximal stomach. With no active bleeding, the midline incision is closed with #1 Maxon suture anchored above and below and tied centrally. The soft tissue is cleaned, skin closed with staples and a CoverDerm. She had received muscle relaxants with her epidural, not breathing on her own and will be taken directly to the ICU on the ventilator without pressors.
I am reviewing an aborted(modifier 52) procedure. I’ve been reviewing 45110,45111,45112,45119,45121 codes, and 37660 for ligation
