Wiki Help with procedure

[KaylaRieken]

**I also posted this in the general surgery section**

I have a patient who underwent a cysto/turbt earlier in the day. Later in the day doctor went back and did exploratory laparotomy, cystorrhaphy, and evacuation of 2.3 liters if saline with evaluation of bowel and intra-abdominal structures. He dictates they dissected down and entered into the peritoneum. At his point, there was moderate amount of fluid that was evacuated out and initially around 300-400 mL of saline was evacuated out of the abdominal cavity. We continued to free up this area and eventually enter the space of Retzius, freeing up the urinary bladder.

Would 49084 be appropriate for this procedure with diagnosis of R18.8?

 

[fwnewbie]

I wouldn't call this "ascites" as this fluid is usually due to pathological process and it is not saline. You've got a bladder repair noted - how did it get damaged?
I believe you are looking at a complication from the earlier procedure causing the massive leakage of saline from the irrigation during the cysto/turp and during post-op catheter irrigation if used.
49084 is an open procedure generally for cancer staging Was the entire repair completed laparoscopically or did they convert to an open incision?
I see you also posted in the general section so I'm going to go look there too.

 

[KaylaRieken]

I know that for the bladder repair I will be coding the 51860. I wasn't sure about the evacuation of the saline portion or if this would just be bundled into the 51860. It was not a laparoscopic procedure. It was all open. The bladder was injured from the previous surgery earlier in the day.

 

[fwnewbie]

Oh duh! I read "laparoscopy"! Anyhoo, I believe the evacuation would be inclusive but it does increase this patient's risk for infection.

 

[KaylaRieken]

I wonder if I should code 51865 instead of 51860? Thoughts?

 

[fwnewbie]

I wouldn't if your doctor feels any responsibility for this complication. The insurance will probably pay, but they shouldn't in my opinion. Doctors yell about malpractice insurance all the time but I don't think they are forthcoming about their responsibility for incidental damages without a legal action being called against them.
I know I feel this way because I have been in at least 2 situations where a physician ignored or missed a critical diagnosis and a death occurred. I realize these were drastic cases. I even had to give a deposition and the whole thing was very traumatizing - both cases have scarred me I'm afraid. So, my opinions are obviously skewed to being a strong patient advocate!

On second thought, maybe coding "complicated" is the best option as it certainly describes the situation.