angelamy
New
I am new to urology coding and ran across a surgery that has me confused. Here is the op note:
"Approximately 3 weeks ago this patient underwent surgical removal of several large stones from a continent diversion pouch. 2 days later became apparent that there was a complication in the form of the small bowel injury. Subsequently, this failed to close on hyperalimentation. Sometime after that, probably 7-10 days, he had a fairly sudden marked decrease in urine output through the pouch catheter with a proportionate increase in wound and Jackson-Pratt drainage. Interventional radiology has confirmed the presence of the pouch leak. He was brought back to surgery this evening to deal with both problems. For all but the pouch repair, Dr.S. was the primary surgeon. He opened, gained exposure, dissected out the involved bowel loops and in the course of doing so we did identify the site of the pouch leak which was indeed at the suture line from the previous pouch closure the original surgery. There was no possibility of debriding the edges. The defect, measuring 1.5-2 cm was closed in 2 layers of running 2-0 PDS. His pouch catheter was replaced with a larger, latex free, 22 French catheter. Was noted to irrigate easily with full returns. Mucus was irrigated from the pouch. With the patch now distended with several 100ml of saline colored with methylene blue. With the patch moderately distended, no leak was observed."
I have looked and researched everywhere and cannot find a code for repair of pouch, so do I use a repair of bladder since this is his bladder now?
All help is appreciated!!!
"Approximately 3 weeks ago this patient underwent surgical removal of several large stones from a continent diversion pouch. 2 days later became apparent that there was a complication in the form of the small bowel injury. Subsequently, this failed to close on hyperalimentation. Sometime after that, probably 7-10 days, he had a fairly sudden marked decrease in urine output through the pouch catheter with a proportionate increase in wound and Jackson-Pratt drainage. Interventional radiology has confirmed the presence of the pouch leak. He was brought back to surgery this evening to deal with both problems. For all but the pouch repair, Dr.S. was the primary surgeon. He opened, gained exposure, dissected out the involved bowel loops and in the course of doing so we did identify the site of the pouch leak which was indeed at the suture line from the previous pouch closure the original surgery. There was no possibility of debriding the edges. The defect, measuring 1.5-2 cm was closed in 2 layers of running 2-0 PDS. His pouch catheter was replaced with a larger, latex free, 22 French catheter. Was noted to irrigate easily with full returns. Mucus was irrigated from the pouch. With the patch now distended with several 100ml of saline colored with methylene blue. With the patch moderately distended, no leak was observed."
I have looked and researched everywhere and cannot find a code for repair of pouch, so do I use a repair of bladder since this is his bladder now?
All help is appreciated!!!