debellis59
Networker
Hi,
I'm hoping someone can give me some advice on this. Doc called in to help with surgery by another physician (3 docs total). He came in and did his part of the surgery and left and this was the op note:
Brief History: I was called in by Dr. F to perform surgery on a uterus which had suffered a gunshot wound and had been split open across the fundus.
Findings: Uterus had been split from side to side, down the middle of the fundus, and had laid open. Dr. Field had already arrested bleeding with electrocautery.
Description of procedure: On my arrival, I examined the uterus and determined that I thought it could be salvaged. The uterus was closed in 2 layers, the inner muscle was closed with interrupted sutures of 2-0 Vicryl and the outer muscle was closed over the top of that, along with the serosa, partially with interrupted, and partially with a running stitch of 2-0 Vicryl. Closure geve good approximation and good appearance to the uterus. Both tubes appeared to be in a position that would likely be functional, although that cannot be guaranteed, since it is not entirely understood how much uterus she lost due to this trauma. I have requested a piece of Seprafilm be placed over the uterus at the closure of the abdomen. Dr. H had done his procedure prior to my coming, and Dr. F continued surgery after I left.
Any help that anyone can offer in coding this would be appreciated. I'm truly at a loss. All I see is using an unlisted procedure ... is this correct?
Thank you
I'm hoping someone can give me some advice on this. Doc called in to help with surgery by another physician (3 docs total). He came in and did his part of the surgery and left and this was the op note:
Brief History: I was called in by Dr. F to perform surgery on a uterus which had suffered a gunshot wound and had been split open across the fundus.
Findings: Uterus had been split from side to side, down the middle of the fundus, and had laid open. Dr. Field had already arrested bleeding with electrocautery.
Description of procedure: On my arrival, I examined the uterus and determined that I thought it could be salvaged. The uterus was closed in 2 layers, the inner muscle was closed with interrupted sutures of 2-0 Vicryl and the outer muscle was closed over the top of that, along with the serosa, partially with interrupted, and partially with a running stitch of 2-0 Vicryl. Closure geve good approximation and good appearance to the uterus. Both tubes appeared to be in a position that would likely be functional, although that cannot be guaranteed, since it is not entirely understood how much uterus she lost due to this trauma. I have requested a piece of Seprafilm be placed over the uterus at the closure of the abdomen. Dr. H had done his procedure prior to my coming, and Dr. F continued surgery after I left.
Any help that anyone can offer in coding this would be appreciated. I'm truly at a loss. All I see is using an unlisted procedure ... is this correct?
Thank you
