Hi everyone,
I have an operative report here and I'm not sure if I can code it as a diagnostic lap or if I can only code it as an intraoperative consult. Please help. Thanks!
Date of Service: March 09, 2014
INTRAOPERATIVE CONSULT AND OPERATIVE NOTE
Please see Dr. note for the full procedure note.
PREOPERATIVE DIAGNOSES
1. Left renal cell carcinoma.
2. Serosal tear and mesenteric defect.
POSTOPERATIVE DIAGNOSES
1. Left renal cell carcinoma.
2. Posterior duodenal serosal tear.
3. Mesenteric defect in the left colon.
PROCEDURE
Abdominal exploration.
ANESTHESIA
General.
INDICATION FOR PROCEDURE
This is a 73-year-old male who was having a left radical nephrectomy
done by Dr. . I was called into the case after the complete
nephrectomy was done as Dr. was concerned about a serosal tear
of the small bowel, as well as a large mesenteric defect. There was an
intraoperative consult done for a general surgeon opinion.
OPERATIVE PROCEDURE IN DETAIL
The patient was already open when I entered the room. I examined the
left colon. The left colon was well-vascularized and had no evidence of
ischemia. I did see a large mesenteric defect; however, this was in a
relatively avascular portion of the mesenteric window and the marginal
artery as well as the left colic and middle colic arteries were intact.
There was no reason to close the defect because of its very large size.
We also examined a posterior serosal tear that started from the ligament
of Treitz and actually extended to the 2nd portion of the duodenum.
I entered the lesser sac using a LigaSure Impact device to examine the duodenum at the C loop. Again, this serosal tear was posteriorly. I
did not feel it was necessary to repair the serosal tear because of the
location, and I was concerned that actually repairing this tear would
make things worse based on its location. Therefore, we left the serosal
tear intact. There was no evidence of enterotomy at any time.
I therefore turned over the procedure back to Dr. for closure.
Please see his operative note.
I have an operative report here and I'm not sure if I can code it as a diagnostic lap or if I can only code it as an intraoperative consult. Please help. Thanks!
Date of Service: March 09, 2014
INTRAOPERATIVE CONSULT AND OPERATIVE NOTE
Please see Dr. note for the full procedure note.
PREOPERATIVE DIAGNOSES
1. Left renal cell carcinoma.
2. Serosal tear and mesenteric defect.
POSTOPERATIVE DIAGNOSES
1. Left renal cell carcinoma.
2. Posterior duodenal serosal tear.
3. Mesenteric defect in the left colon.
PROCEDURE
Abdominal exploration.
ANESTHESIA
General.
INDICATION FOR PROCEDURE
This is a 73-year-old male who was having a left radical nephrectomy
done by Dr. . I was called into the case after the complete
nephrectomy was done as Dr. was concerned about a serosal tear
of the small bowel, as well as a large mesenteric defect. There was an
intraoperative consult done for a general surgeon opinion.
OPERATIVE PROCEDURE IN DETAIL
The patient was already open when I entered the room. I examined the
left colon. The left colon was well-vascularized and had no evidence of
ischemia. I did see a large mesenteric defect; however, this was in a
relatively avascular portion of the mesenteric window and the marginal
artery as well as the left colic and middle colic arteries were intact.
There was no reason to close the defect because of its very large size.
We also examined a posterior serosal tear that started from the ligament
of Treitz and actually extended to the 2nd portion of the duodenum.
I entered the lesser sac using a LigaSure Impact device to examine the duodenum at the C loop. Again, this serosal tear was posteriorly. I
did not feel it was necessary to repair the serosal tear because of the
location, and I was concerned that actually repairing this tear would
make things worse based on its location. Therefore, we left the serosal
tear intact. There was no evidence of enterotomy at any time.
I therefore turned over the procedure back to Dr. for closure.
Please see his operative note.