Hi, how would you code this? I was thinking 49000 and 58662? Or is it more accurate to code the discontinuation of the open nephroureterectomy? Thanks!!
POSTOPERATIVE DIAGNOSIS:
Right ureteral stricture, atrophic right kidney.
PROCEDURE PERFORMED:
Exploratory laparotomy.
ANESTHESIA:
General laryngeal mask.
INDICATIONS:
The patient has the above, elected to undergo a right nephroureterectomy to avoid having to be managed with a stent.
FINDINGS:
Dense intraabdominal adhesions preventing hand-assisted laparoscopic approach. Open approach was performed. There again were dense intraabdominal adhesions were taken down. The kidney was exposed. However, the kidney was densely scarred in and at the area of the ureteropelvic junction was a mass of scar extending at least 3 to 4 cm adherent to the vena cava. It was felt that attempted resection would risk significant caval compromise and therefore the procedure was not performed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and after general laryngeal mask anesthesia was obtained, she was prepped and draped in a sterile fashion in the right-side-up position. The right lower quadrant incision was made for HandPort. Dissection carried down to the rectus fascia, which was opened and rectus muscle was incised and peritoneum was entered, but there were dense anterior adhesions to the abdominal wall throughout. It was not felt that laparoscopic procedure could be performed. Attention was then turned to an open procedure. Right subcostal incision was made, taken down through rectus fascia and rectus muscle. Peritoneum was entered. There were dense adhesions to the anterior abdominal wall, liver, and right lateral wall as well as posteriorly. These were all meticulously taken down and the retroperitoneal space where the kidney was exposed. The renal vein could be seen coming off the vena cava and again the kidney was densely encased in scar and the area of the ureteropelvic junction that has very dense scar tissue. This was extensively adhered to the vena cava for at least a length of about 5 cm and below this I could not palpate the ureter either and there were still scar tissue. Decision at that point was made not to proceed with surgical removal of the kidney because of the very high risk of caval interruption and compromise. Therefore, hemostasis was obtained. The wound was closed with a running double-looped PDS as was the laparoscopic HandPort. Prior to this, lap, sponge and instrument counts were noted to be correct by nursing staff. Subcutaneous tissue closed with running 3-0 Vicryl. Skin closed with staples and injected with 0.25% Marcaine. The patient was awakened from anesthesia, left the room in good condition.
POSTOPERATIVE DIAGNOSIS:
Right ureteral stricture, atrophic right kidney.
PROCEDURE PERFORMED:
Exploratory laparotomy.
ANESTHESIA:
General laryngeal mask.
INDICATIONS:
The patient has the above, elected to undergo a right nephroureterectomy to avoid having to be managed with a stent.
FINDINGS:
Dense intraabdominal adhesions preventing hand-assisted laparoscopic approach. Open approach was performed. There again were dense intraabdominal adhesions were taken down. The kidney was exposed. However, the kidney was densely scarred in and at the area of the ureteropelvic junction was a mass of scar extending at least 3 to 4 cm adherent to the vena cava. It was felt that attempted resection would risk significant caval compromise and therefore the procedure was not performed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and after general laryngeal mask anesthesia was obtained, she was prepped and draped in a sterile fashion in the right-side-up position. The right lower quadrant incision was made for HandPort. Dissection carried down to the rectus fascia, which was opened and rectus muscle was incised and peritoneum was entered, but there were dense anterior adhesions to the abdominal wall throughout. It was not felt that laparoscopic procedure could be performed. Attention was then turned to an open procedure. Right subcostal incision was made, taken down through rectus fascia and rectus muscle. Peritoneum was entered. There were dense adhesions to the anterior abdominal wall, liver, and right lateral wall as well as posteriorly. These were all meticulously taken down and the retroperitoneal space where the kidney was exposed. The renal vein could be seen coming off the vena cava and again the kidney was densely encased in scar and the area of the ureteropelvic junction that has very dense scar tissue. This was extensively adhered to the vena cava for at least a length of about 5 cm and below this I could not palpate the ureter either and there were still scar tissue. Decision at that point was made not to proceed with surgical removal of the kidney because of the very high risk of caval interruption and compromise. Therefore, hemostasis was obtained. The wound was closed with a running double-looped PDS as was the laparoscopic HandPort. Prior to this, lap, sponge and instrument counts were noted to be correct by nursing staff. Subcutaneous tissue closed with running 3-0 Vicryl. Skin closed with staples and injected with 0.25% Marcaine. The patient was awakened from anesthesia, left the room in good condition.