Retrophaze
Contributor
I am hoping to have some help with the below report. At times our management questions why we didn't code something therefore the codes use on this were 43640, 43610-59. The reasoning behind coding the 43610 was that it was sent out for pathology. Thing is, it was excised and not just biopsied. Any thoughts?
Exploration revealed a large antral ulcer anteriorly. This antral ulcer is adjacent to the pylorus. I cut out the ulcer and submitted it for histopathology to check for cancer. Next, the pylorus was cut open and pyloroplasty was carried out using 2 layer closure. …… Then, the vagal nerves were identified. The left anterior vagal nerve was first identified and a right angle clamp was used to hold it up and 2 clips were placed proximal and distal prior to its division. The peritoneum between the esophagus and liver was opened up and the esophagus was dissected circumferential. The posterior right vagal nerve was identified and a right angle clamp was used to hold it up followed by the nerve foot and the clip was placed proximal and distal x2 and vagal nerve was divided.
Exploration revealed a large antral ulcer anteriorly. This antral ulcer is adjacent to the pylorus. I cut out the ulcer and submitted it for histopathology to check for cancer. Next, the pylorus was cut open and pyloroplasty was carried out using 2 layer closure. …… Then, the vagal nerves were identified. The left anterior vagal nerve was first identified and a right angle clamp was used to hold it up and 2 clips were placed proximal and distal prior to its division. The peritoneum between the esophagus and liver was opened up and the esophagus was dissected circumferential. The posterior right vagal nerve was identified and a right angle clamp was used to hold it up followed by the nerve foot and the clip was placed proximal and distal x2 and vagal nerve was divided.