Need some help with this scenario.
Can I bill for the repair? If so which cpt code should I use?
Thanks for the help.
FINDINGS: The duodenum was quite adherent, in the process of taking it down, serosal tear had occurred in the duodenum and I decided to open the patient to examine it more carefully and repair it. The cholecystectomy proceeded unremarkably, gallstones, and intraoperative cholangiogram normal.
DETAILS OF PROCEDURE: The patient was identified preoperatively and consent had been obtained, brought to the operating room and placed on the operating table in supine position. Under satisfactory anesthesia, an incision was made beneath the umbilicus down to the fascia. It was divided in the midline. Stay sutures were placed in peritoneal cavity, and Hasson was inserted into the peritoneal cavity and the space insufflated to 15 mmHg. The remaining ports were then placed in normal position. The gallbladder was grasped at the fundus and retracted superiorly and then the duodenum, which was adherent to it was retracted down carefully; however, despite that because it was so adherent, a partial-thickness tear created in the duodenum. The cystic duct was dissected out from surrounding structures. A clip was placed on it proximally. An incision was made in the cystic duct. The cholangiocatheter was inserted into cystic duct and clipped in place. Intraoperative cholangiogram performed with findings as noted. Catheter and clip were then removed. The duct was clipped 3 times distally and divided. Cystic artery was identified. There were 2 branches that were clipped and cut and then the gallbladder was dissected off the liver bed and placed in an EndoCatch bag and removed. The area was irrigated copiously. The duodenum was inspected and it was decided to open to examine it more carefully.
A midline incision was then completed between the 2 superior incisions down to a peritoneal cavity and the Bookwalter retractor was used for exposure, and then the duodenum was examined, and there was a small area of partial thickness tear in its proximal portion on the anterior aspect, and the wounds were closed with 3-0 silk suture to close up that area of the duodenum and then omentum was placed over the area as well, and secured in place with silk suture and then a 10 flat Jackson-Pratt drain was placed as well. The fascia was closed with figure-of-eight #1 PDS sutures. The skin with skin staples. Clean and dry dressings were applied. The patient tolerated the procedure well and was taken to recovery in satisfactory condition. At the end of the case, counts were correct.
Can I bill for the repair? If so which cpt code should I use?
Thanks for the help.
FINDINGS: The duodenum was quite adherent, in the process of taking it down, serosal tear had occurred in the duodenum and I decided to open the patient to examine it more carefully and repair it. The cholecystectomy proceeded unremarkably, gallstones, and intraoperative cholangiogram normal.
DETAILS OF PROCEDURE: The patient was identified preoperatively and consent had been obtained, brought to the operating room and placed on the operating table in supine position. Under satisfactory anesthesia, an incision was made beneath the umbilicus down to the fascia. It was divided in the midline. Stay sutures were placed in peritoneal cavity, and Hasson was inserted into the peritoneal cavity and the space insufflated to 15 mmHg. The remaining ports were then placed in normal position. The gallbladder was grasped at the fundus and retracted superiorly and then the duodenum, which was adherent to it was retracted down carefully; however, despite that because it was so adherent, a partial-thickness tear created in the duodenum. The cystic duct was dissected out from surrounding structures. A clip was placed on it proximally. An incision was made in the cystic duct. The cholangiocatheter was inserted into cystic duct and clipped in place. Intraoperative cholangiogram performed with findings as noted. Catheter and clip were then removed. The duct was clipped 3 times distally and divided. Cystic artery was identified. There were 2 branches that were clipped and cut and then the gallbladder was dissected off the liver bed and placed in an EndoCatch bag and removed. The area was irrigated copiously. The duodenum was inspected and it was decided to open to examine it more carefully.
A midline incision was then completed between the 2 superior incisions down to a peritoneal cavity and the Bookwalter retractor was used for exposure, and then the duodenum was examined, and there was a small area of partial thickness tear in its proximal portion on the anterior aspect, and the wounds were closed with 3-0 silk suture to close up that area of the duodenum and then omentum was placed over the area as well, and secured in place with silk suture and then a 10 flat Jackson-Pratt drain was placed as well. The fascia was closed with figure-of-eight #1 PDS sutures. The skin with skin staples. Clean and dry dressings were applied. The patient tolerated the procedure well and was taken to recovery in satisfactory condition. At the end of the case, counts were correct.