lindacoder
Guest
Scheduled as a laparoscopic cholecystectomy. Would you bill 47562 with 53 modifier or just 49320?
PREOPERATIVE DIAGNOSIS: Cholelithiasis.
POSTOPERATIVE DIAGNOSIS: Severe macronodular cirrhosis with ascites.
PROCEDURES PERFORMED: Diagnostic laparoscopy.
SURGEON: Counseling MD
ANESTHESIA: General.
PATHOLOGY SPECIMEN SENT: None.
ESTIMATED BLOOD LOSS: 50 mL.
DESCRIPTION OF SURGERY: The patient was brought to the operating room and general anesthesia induced. The abdomen was sterilely prepped and draped in usual fashion. The abdomen was entered through a small incision below the umbilicus using the Optiview port site technique. A good pneumoperitoneum at 15 mmHg was obtained without difficulty. Laparoscope was inserted. There was no evidence of any intraabdominal injury from the trocar insertion. Under direct visualization, a 12 mm trocar was then placed to the right of the patient's falciform ligament followed by two 5 mm trocars along the midclavicular anterior axillary lines. The patient was then placed in a steep reverse Trendelenburg position. Of note, the liver was diffusely macular nodular in appearance. There was evidence of cirrhosis in the perihepatic spaces. The gallbladder did have some omentum sucked about it, this was taken down with Harmonic; however, on manipulation of the gallbladder there was probably a 50 mL bleed from the liver bed with just simply grasping the gallbladder. Therefore, due to the severe liver disease and obvious friability of the liver bed from this the procedure was aborted. Therefore, the patient was placed back in supine position. The pneumoperitoneum was released and trocars were removed. The patient was then awakened from anesthesia, extubated and transferred to the recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Cholelithiasis.
POSTOPERATIVE DIAGNOSIS: Severe macronodular cirrhosis with ascites.
PROCEDURES PERFORMED: Diagnostic laparoscopy.
SURGEON: Counseling MD
ANESTHESIA: General.
PATHOLOGY SPECIMEN SENT: None.
ESTIMATED BLOOD LOSS: 50 mL.
DESCRIPTION OF SURGERY: The patient was brought to the operating room and general anesthesia induced. The abdomen was sterilely prepped and draped in usual fashion. The abdomen was entered through a small incision below the umbilicus using the Optiview port site technique. A good pneumoperitoneum at 15 mmHg was obtained without difficulty. Laparoscope was inserted. There was no evidence of any intraabdominal injury from the trocar insertion. Under direct visualization, a 12 mm trocar was then placed to the right of the patient's falciform ligament followed by two 5 mm trocars along the midclavicular anterior axillary lines. The patient was then placed in a steep reverse Trendelenburg position. Of note, the liver was diffusely macular nodular in appearance. There was evidence of cirrhosis in the perihepatic spaces. The gallbladder did have some omentum sucked about it, this was taken down with Harmonic; however, on manipulation of the gallbladder there was probably a 50 mL bleed from the liver bed with just simply grasping the gallbladder. Therefore, due to the severe liver disease and obvious friability of the liver bed from this the procedure was aborted. Therefore, the patient was placed back in supine position. The pneumoperitoneum was released and trocars were removed. The patient was then awakened from anesthesia, extubated and transferred to the recovery room in stable condition.