All advice is welcomed. I am a plastics and derm coder, I dabble in some surgery, but this op note has the surgeon and assistant surgeon disagreeing about what was done. I need experienced minds to check my coding--the docs can discuss their issues separately. I want to submit the correct codes per the op report.
So far I have 44145, 44139 for CPT codes. DX codes 562.10 (as documented, but diverticulosis won't cause the damage if it's not inflamed, so I think it should be 562.11), 569.81
Thanks in advance.
Lynn
****
POSTOPERATIVE DIAGNOSIS: Colovesicular fistula, urinary tract infection, diverticulosis, rule out cirrhosis, coagulopathy, superior mesenteric vein thrombosis.
FINDINGS: General surgical findings were a colovesical (sic) fistula involving the sigmoid colon. The extent of the diverticular disease extended throught the entire left colon, up to and involving the splenic flexure. The urologic findings are as per Dr. X (urologist). The small bowel was unremarkable, as was the spleen. The gallbladder and the liver felt minimally nodular. The rectum was unremarkable.
PROCEDURE:
...The urologic procedures were as noted and were performed by Dr. X.
The abdomen and peritoneum were then prepped and draped in the usual sterile fashion. The lower extremities were also draped sterilely. Then a generous midline incision was made and sustained down through the skin and the subcutaneous tissue. Hemostasis was achieved with the use of the Bovie. The incision was then carried down through the subcutaneous tissue and fascia and subsequently into the abdomen. On entering the abdomen, the above-mentioned findings were noted. There was significant adiposity, both involving the omentum and the colon itself. The fistula was resected using mostly the Bovie. The nature of the fistulous track was very fibrotic and there was difficult resection during this separation. At this juncture, care was taken to identify and preserve the ureters during this difficult resection. Once the dissection was completed, the urologist repaired the bladder as noted.
Then the entire left colon was mobiled along the line of Toldt. The mobilization was carried down to the proximal rectum and up to the mid-transverse colon. The disease extended up to and around the splenic flexure. There was significant adiposity as well as contractions secondary to the disease process. During the mobilization of the left distal transverse colon, hemostasis was achieved with the use of Bovie and also with 0 Vicryl ties. The named vessels were doubly ligated with 0 silk. The entire left distal transverse colon was then mobilized. The distal colon was then transected using the articulator at the proximal rectum. The proximal colon was then transected at the mid-transverse colon. Hemostasis again was achieved with the use of the Bovie, as well as with 0 Vicryl and 0 silk ties. The anastomosis was carried out using the EEA via the rectum, which was previously irrigated prior to the start of surgery. Care was taken not to have any tension or rotation of the colon during this anastomosis. It was checked with air and there were no leaks noted. Four tangentially placed sutures were placed between the proximal rectum and the colon using 3-0 GI silk. There was a portion of omentum that was inflamed and this was removed between Kelly clamps and ligated with 0 Vicryl. At this point, goves were changed and the entire abdomen was irrigated copiously in all quadrants until effluent was clear......
So far I have 44145, 44139 for CPT codes. DX codes 562.10 (as documented, but diverticulosis won't cause the damage if it's not inflamed, so I think it should be 562.11), 569.81
Thanks in advance.
Lynn
****
POSTOPERATIVE DIAGNOSIS: Colovesicular fistula, urinary tract infection, diverticulosis, rule out cirrhosis, coagulopathy, superior mesenteric vein thrombosis.
FINDINGS: General surgical findings were a colovesical (sic) fistula involving the sigmoid colon. The extent of the diverticular disease extended throught the entire left colon, up to and involving the splenic flexure. The urologic findings are as per Dr. X (urologist). The small bowel was unremarkable, as was the spleen. The gallbladder and the liver felt minimally nodular. The rectum was unremarkable.
PROCEDURE:
...The urologic procedures were as noted and were performed by Dr. X.
The abdomen and peritoneum were then prepped and draped in the usual sterile fashion. The lower extremities were also draped sterilely. Then a generous midline incision was made and sustained down through the skin and the subcutaneous tissue. Hemostasis was achieved with the use of the Bovie. The incision was then carried down through the subcutaneous tissue and fascia and subsequently into the abdomen. On entering the abdomen, the above-mentioned findings were noted. There was significant adiposity, both involving the omentum and the colon itself. The fistula was resected using mostly the Bovie. The nature of the fistulous track was very fibrotic and there was difficult resection during this separation. At this juncture, care was taken to identify and preserve the ureters during this difficult resection. Once the dissection was completed, the urologist repaired the bladder as noted.
Then the entire left colon was mobiled along the line of Toldt. The mobilization was carried down to the proximal rectum and up to the mid-transverse colon. The disease extended up to and around the splenic flexure. There was significant adiposity as well as contractions secondary to the disease process. During the mobilization of the left distal transverse colon, hemostasis was achieved with the use of Bovie and also with 0 Vicryl ties. The named vessels were doubly ligated with 0 silk. The entire left distal transverse colon was then mobilized. The distal colon was then transected using the articulator at the proximal rectum. The proximal colon was then transected at the mid-transverse colon. Hemostasis again was achieved with the use of the Bovie, as well as with 0 Vicryl and 0 silk ties. The anastomosis was carried out using the EEA via the rectum, which was previously irrigated prior to the start of surgery. Care was taken not to have any tension or rotation of the colon during this anastomosis. It was checked with air and there were no leaks noted. Four tangentially placed sutures were placed between the proximal rectum and the colon using 3-0 GI silk. There was a portion of omentum that was inflamed and this was removed between Kelly clamps and ligated with 0 Vicryl. At this point, goves were changed and the entire abdomen was irrigated copiously in all quadrants until effluent was clear......