AR2728
Expert
I'm wondering if this is enough to code as a discontinued hernia repair (mod 53) procedure or go with unlisted code for groin exploration only.
PREOP DIAG: Recurrent right inguinal hernia
POSTOPERATIVE DIAGNOSIS:
Same, with findings of dilated groin vessels and abnormal bleeding tendency
PROCEDURE PERFORMED: Right groin exploration
OPERATIVE NOTE: The patient was taken to the operating room, placed in the supine position, administered general anesthesia via the endotracheal route. He then had his right groin prepped and draped in the usual sterile fashion. An old incision was noted but this was in a location that could not be used and therefore right groin incision was made from pubic tubercle towards the anterior superior iliac spine through this going 5 cm and caried through the subcutaneous tissue with sharp dissection down to the level of thickened external oblique aponeurosis. There was evidence of dilated vessels encountered on dissec ion that had to be tied off with silk and these were noted in the subcutaneous tissue and above the inguinal canal. The external oblique aponeurosis was then cut but there were findings of marked dilation of vessels beneath the external oblique aponeurosis that could not be safely separated from the external oblique aponeurosis and when this was encountered the decision was made to terminate any further dissection, recognizing that a bleeding complication could be encountered and therefore the external oblique aponeurosis was closed with interrupted #0 Ethibond sutures and the decision was made to terminate any further dissection....
PREOP DIAG: Recurrent right inguinal hernia
POSTOPERATIVE DIAGNOSIS:
Same, with findings of dilated groin vessels and abnormal bleeding tendency
PROCEDURE PERFORMED: Right groin exploration
OPERATIVE NOTE: The patient was taken to the operating room, placed in the supine position, administered general anesthesia via the endotracheal route. He then had his right groin prepped and draped in the usual sterile fashion. An old incision was noted but this was in a location that could not be used and therefore right groin incision was made from pubic tubercle towards the anterior superior iliac spine through this going 5 cm and caried through the subcutaneous tissue with sharp dissection down to the level of thickened external oblique aponeurosis. There was evidence of dilated vessels encountered on dissec ion that had to be tied off with silk and these were noted in the subcutaneous tissue and above the inguinal canal. The external oblique aponeurosis was then cut but there were findings of marked dilation of vessels beneath the external oblique aponeurosis that could not be safely separated from the external oblique aponeurosis and when this was encountered the decision was made to terminate any further dissection, recognizing that a bleeding complication could be encountered and therefore the external oblique aponeurosis was closed with interrupted #0 Ethibond sutures and the decision was made to terminate any further dissection....