SienTC1720
Networker
The surgeon I code for was called in for an intraoperative consult, on a patient having a laparoscopic salpingo-oophorectomy:
The Veress needle was inserted at the level of the umbilicus but was not successful and a 12 mm port Hassan was inserted instead. A 5 mm port was in the suprapubic position. There was noted to be a hematoma in the retroperitoneum inferior to the Veress needle insertion site, and I was called to consult. Upon examination, there was a hematoma which measured about 5 cm in the superior inferior direction and about 3 cm in the medial to lateral direction slightly to the right of midline, extending from just below the umbilicus where there was a small puncture site into the retroperitoneum, and the hematoma extended in a cephalad direction. The hematoma was not tense. It was not expanding. The hematoma was observed for 15 minutes, no expansion was noted. Gas was allowed to escape from the abdominal cavity relieving the pneumoperitoneum. The hematoma was reinspected, no evidence of expansion was noted, and there was no evidence of bowel injury. The hematoma appeared to be inferior to the mesentery of small bowel. The iliac was cephalad to the hematoma. The hematoma was from a venous injury and was stable and nonexpanding, therefore recommended that no exploration of the hematoma will be performed and that the patient will be observed.
Can I bill for this consult, and what code should I use?
The Veress needle was inserted at the level of the umbilicus but was not successful and a 12 mm port Hassan was inserted instead. A 5 mm port was in the suprapubic position. There was noted to be a hematoma in the retroperitoneum inferior to the Veress needle insertion site, and I was called to consult. Upon examination, there was a hematoma which measured about 5 cm in the superior inferior direction and about 3 cm in the medial to lateral direction slightly to the right of midline, extending from just below the umbilicus where there was a small puncture site into the retroperitoneum, and the hematoma extended in a cephalad direction. The hematoma was not tense. It was not expanding. The hematoma was observed for 15 minutes, no expansion was noted. Gas was allowed to escape from the abdominal cavity relieving the pneumoperitoneum. The hematoma was reinspected, no evidence of expansion was noted, and there was no evidence of bowel injury. The hematoma appeared to be inferior to the mesentery of small bowel. The iliac was cephalad to the hematoma. The hematoma was from a venous injury and was stable and nonexpanding, therefore recommended that no exploration of the hematoma will be performed and that the patient will be observed.
Can I bill for this consult, and what code should I use?