smerriweather1
Networker
I submitted a claim for the note below for payment of 43280-22 and 49560. The payer denied the operative note below payment for a 43280-22 and considered the 49560 a bundled service to the line they denied!!!! Need advice as this does not seem correct. I could not find an example of the guidelines of this service. I want to know did I correctly code this case correctly.
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Diagnoses: Hiatal hernia with obstruction but no gangrene; Incisional hernia without obstruction or gangrene; Abdominal adhesions
Date of Surgery
02/21/2017.
Pre-Operative diagnosis
Hiatal hernia with obstruction but no gangrene (ICD10-CM K44.0, Admitting, Medical).
Post-Operative diagnosis
Hiatal hernia with obstruction but no gangrene (ICD10-CM K44.0, Admitting, Medical).
Incisional hernia without obstruction or gangrene (ICD10-CM K43.2, Admitting, Medical).
Abdominal adhesions (ICD10-CM K66.0, Admitting, Medical).
Procedure performed
Diagnostic laparoscopy.
Laparoscopic lysis of adhesions.
Conversion to exploratory laparotomy,
Reduction of incarcerated hiatal hernia, primary repaired of the hiatal hernia.
Gastropexy
Repaired of incisional hernia.
Partial omentectomy..
Specimen obtained
Part of the omentum. .
Anesthesia
General: endotracheal.
Complications
None apparent.
Peripheral catheter
Inserted 02/21/2017.
Indication
Incarcerated hiatal hernia with gastric outlet obstruction. .
Preparation and technique
Medication prior to procedure.
Monitoring during procedure: blood pressure monitoring, cardiac monitor, pulse ox.
Sterile preparation of site: with 2% chlorhexidine gluconate.
Position: supine.
Intra-Operative Details
The patient was taken to the operating room and placed in a supine position. His lower extremities was placed on the yellow fins in a straight position. Bean bag was placed on the bed to support the patient. Briefing was conducted by identifying the patient and confirming the surgical procedure. Intravenous antibiotic was given prior to skin incision. The patient was provided with endotracheal general anesthesia. The abdomen was prepped and draped in the usual sterile fashion. A right paraumbilical incision was performed. The umbilicus was lifted up and the Veress needle was inserted into the abdominal cavity. The abdominal cavity was insufflated with CO2 gas to form a pneumoperitoneum. The Veress needle was removed and a 10 mm trocar was inserted in the right paraumbilical incision. After the trocar was in placed, the 10 mm laparoscope was introduced in the abdominal cavity through the trocar. A 5 mm trocar was inserted in the right upper quadrant of the abdomen for the liver retractor. The liver retractor was set in place, it was self retaining. Two 5 mm trocars were inserted into the abdominal cavity under direct vision. The two were at the left subcostal area, for dissection. The abdomen was examined. The left lobe of the liver was lifted up through the self supporting liver retractor. We noted a large part of the stomach was tightly incarcerated into the thoracic cavity through the hiatal hernia. The incarcerated stomach and omentum were reduced gently with the grasping forceps. The incarcerated omentum can not completely reduced, we decided at this point to convert the procedure into an open laparotomy. Prior to making the skin incision, the adhesions were lysed using the Endoscissors. Skin incision with scalpel blade 10 was made from the subxiphoid to the supraumbilical area. The incision was further dissected using Bovie cautery. The subcutaneous tissue, fascia and peritoneum were incised. The abdominal cavity was entered. The Book Walter retractor was applied. The incarcerated stomach and omentum were gently and completely reduced. The two cruxes of the diaphragm were identified and closed with a series of interrupted 2-0 silk sutures. The hiatal opening was large. The hiatal hernia was primarily closed, it allows one finger tip to pass through the hernia after the repair. The stomach was tacked to the crux during the closure of the hiatal hernia. We pumped air into the esophagus to make sure there was no air leak, there was none. This was tested twice. After the hiatal hernia was closed, gastropexy was done to the abdominal wall, to keep the stomach was sliding back to the thoracic cavity. Part of the omentum were resected, using clamp, cut and tie technique. The abdominal cavity was irrigated with copious amount of saline prior to closing the incision. An incisional hernia was repaired at the fascia level using a series of interrupted figure of 8 Prolene suture prior to skin closure. The incision was closed in layers. The peritoneum was closed with a continuous running 2-0 Vicryl suture. The fascia was closed with a series of interrupted figure of 8, number 1 Vicryl sutures. The skin was closed with skin staples. All the trocar sites were closed with skin staples. The 10 mm trocar site was closed at the fascia level using the Endo closed stitch prior to closing the skin. Instruments, needles and sponges count were reported to be correct, patient tolerated the procedure well, He we taken to the recovery room in stable condition.
Findings Incarcerated hiatal hernia with obstruction. Part of the stomach was in the thoracic cavity with a large portion of the omentum. .
Condition Good.
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Diagnoses: Hiatal hernia with obstruction but no gangrene; Incisional hernia without obstruction or gangrene; Abdominal adhesions
Date of Surgery
02/21/2017.
Pre-Operative diagnosis
Hiatal hernia with obstruction but no gangrene (ICD10-CM K44.0, Admitting, Medical).
Post-Operative diagnosis
Hiatal hernia with obstruction but no gangrene (ICD10-CM K44.0, Admitting, Medical).
Incisional hernia without obstruction or gangrene (ICD10-CM K43.2, Admitting, Medical).
Abdominal adhesions (ICD10-CM K66.0, Admitting, Medical).
Procedure performed
Diagnostic laparoscopy.
Laparoscopic lysis of adhesions.
Conversion to exploratory laparotomy,
Reduction of incarcerated hiatal hernia, primary repaired of the hiatal hernia.
Gastropexy
Repaired of incisional hernia.
Partial omentectomy..
Specimen obtained
Part of the omentum. .
Anesthesia
General: endotracheal.
Complications
None apparent.
Peripheral catheter
Inserted 02/21/2017.
Indication
Incarcerated hiatal hernia with gastric outlet obstruction. .
Preparation and technique
Medication prior to procedure.
Monitoring during procedure: blood pressure monitoring, cardiac monitor, pulse ox.
Sterile preparation of site: with 2% chlorhexidine gluconate.
Position: supine.
Intra-Operative Details
The patient was taken to the operating room and placed in a supine position. His lower extremities was placed on the yellow fins in a straight position. Bean bag was placed on the bed to support the patient. Briefing was conducted by identifying the patient and confirming the surgical procedure. Intravenous antibiotic was given prior to skin incision. The patient was provided with endotracheal general anesthesia. The abdomen was prepped and draped in the usual sterile fashion. A right paraumbilical incision was performed. The umbilicus was lifted up and the Veress needle was inserted into the abdominal cavity. The abdominal cavity was insufflated with CO2 gas to form a pneumoperitoneum. The Veress needle was removed and a 10 mm trocar was inserted in the right paraumbilical incision. After the trocar was in placed, the 10 mm laparoscope was introduced in the abdominal cavity through the trocar. A 5 mm trocar was inserted in the right upper quadrant of the abdomen for the liver retractor. The liver retractor was set in place, it was self retaining. Two 5 mm trocars were inserted into the abdominal cavity under direct vision. The two were at the left subcostal area, for dissection. The abdomen was examined. The left lobe of the liver was lifted up through the self supporting liver retractor. We noted a large part of the stomach was tightly incarcerated into the thoracic cavity through the hiatal hernia. The incarcerated stomach and omentum were reduced gently with the grasping forceps. The incarcerated omentum can not completely reduced, we decided at this point to convert the procedure into an open laparotomy. Prior to making the skin incision, the adhesions were lysed using the Endoscissors. Skin incision with scalpel blade 10 was made from the subxiphoid to the supraumbilical area. The incision was further dissected using Bovie cautery. The subcutaneous tissue, fascia and peritoneum were incised. The abdominal cavity was entered. The Book Walter retractor was applied. The incarcerated stomach and omentum were gently and completely reduced. The two cruxes of the diaphragm were identified and closed with a series of interrupted 2-0 silk sutures. The hiatal opening was large. The hiatal hernia was primarily closed, it allows one finger tip to pass through the hernia after the repair. The stomach was tacked to the crux during the closure of the hiatal hernia. We pumped air into the esophagus to make sure there was no air leak, there was none. This was tested twice. After the hiatal hernia was closed, gastropexy was done to the abdominal wall, to keep the stomach was sliding back to the thoracic cavity. Part of the omentum were resected, using clamp, cut and tie technique. The abdominal cavity was irrigated with copious amount of saline prior to closing the incision. An incisional hernia was repaired at the fascia level using a series of interrupted figure of 8 Prolene suture prior to skin closure. The incision was closed in layers. The peritoneum was closed with a continuous running 2-0 Vicryl suture. The fascia was closed with a series of interrupted figure of 8, number 1 Vicryl sutures. The skin was closed with skin staples. All the trocar sites were closed with skin staples. The 10 mm trocar site was closed at the fascia level using the Endo closed stitch prior to closing the skin. Instruments, needles and sponges count were reported to be correct, patient tolerated the procedure well, He we taken to the recovery room in stable condition.
Findings Incarcerated hiatal hernia with obstruction. Part of the stomach was in the thoracic cavity with a large portion of the omentum. .
Condition Good.