KBean2018
Guru
Hello, Can the below be coded as 49000? The Surgeon provided this note because he was not the primary assistant to a procedure. Another OR surgeon assisted and was able to get the main procedure code. I'm not sure how to code this.
Postoperative Diagnosis:
Ruptured stomach ulcer
*
Procedure:
Intraop consultation
Exploration of pelvis
*Findings:
Normal post operative findings in pelvix
*
Procedure:
presents for abdominal pain and leukocytosis. Patient is on a multi-antibiotic regimen. Primary Surgeon made a midline vertical incision and explored the abdomen. At that time with me present it was discovered she had a perforated stomach or duodenal ulcer. Prior to repairing this I explore the pelvis. The right adnexa is removed with sutures still in place. No signs of infection in this area. Her uterus is very small mobile and soft. The left adnexa is also normal-appearing. No signs or symptoms of TOA on the left. At this time Primary Doctor and his PA performed the remainder of the surgery.
Postoperative Diagnosis:
Ruptured stomach ulcer
*
Procedure:
Intraop consultation
Exploration of pelvis
*Findings:
Normal post operative findings in pelvix
*
Procedure:
presents for abdominal pain and leukocytosis. Patient is on a multi-antibiotic regimen. Primary Surgeon made a midline vertical incision and explored the abdomen. At that time with me present it was discovered she had a perforated stomach or duodenal ulcer. Prior to repairing this I explore the pelvis. The right adnexa is removed with sutures still in place. No signs of infection in this area. Her uterus is very small mobile and soft. The left adnexa is also normal-appearing. No signs or symptoms of TOA on the left. At this time Primary Doctor and his PA performed the remainder of the surgery.