Wiki Lap surgery help, please.

[Jessim929]

I have a case where patient underwent a left hand-assisted radical nephrectomy and then had to go back for a diagnostic hand-assisted laparoscopy, vessel ligation, clot evacuation and hematoma evacuation later that day.

I'm struggling with the code(s).

Patient had unstable BP post-op and abdomen distention and the dressing was blood soaked. Doctor felt there may have been internal bleeding. Went back to OR (mod-78, I know). Staples were removed and a lap was placed into the abdomen by hand reaching back to left retroperitoneal space where original dissection of left kidney was. Lap was not soaked when removed. Two trocars were placed from the 2 sites under direct palpation into abdomen, GelPort at midline and once insufflated, doctor placed his hand into abdomen then camera. Left colon was reflected off space to expose. Blood pool found. Site not identified. All blood and clot removed with suction and irrigation. Incision line intact with no active bleeding. Exposed vessel found - appeared to be collateral not accessory vein - with slight oozing. 2 Hemoclips immediately placed. 20 minutes of observation with intermittent irrigation followed. Patient stabilized and closed up.

I came up with 49322, but when I look again it doesn't seem correct. Any better suggestions?

Thanks in advance!!

 

[scronin]

The codes 49322 or 49320 would be accurate to the procedure documented, however, I would report the code 49322 since it is a better representation of the procedure performed. You could not report the control of bleeding separately as it is included in this code. A 78 modifier would be reported as well.