KBean2018
Guru
*Hello, would I code the liver resection as 47120? I cannot find a code for the liver sonogram. Any advice? Thanks so much
CPT Code: Procedures:
* LIVER RESECTION
* INTRAOPERATIVE LIVER SONOGRAM
*
*
ICD-10 : Post-Op Diagnosis Codes:
* Liver metastases (HCC) [C78.7]
*
Findings: After releasing the triangular ligament and diaphragmatic attachments of the right liver, with pads elevating the mobilize right liver, anterior exposure of the palpable mass is good with directed sonogram showing a venous outflow slightly inferior and medial. A trough is made surrounding the identified mass, about 1.5 cm margins, deepened about 1 cm with hook cautery and the mass specimen elevated from medial to lateral using Harmonic ACE. The ergometry design of this Harmonic instrument is awkward, as I come from medial to lateral I have bleeding as expected but the specimen fractures and I can palpate proximity of tumor with the deep margin and I quickly amputate and then removed the remainder of the scored posterior lateral component, quickly removing with hook cautery. Blood loss is about 100-150 mL through this and I hemostatically closed with 3 horizontally placed 0 chromic sutures on a liver needle. No other liver lesions are identified. I mobilize the right colic omentum but the remainder the omentum is tethered to the lower midline incision and cannot be easily mobilized without extending the incision, so I used a 5 x 4 x 2 cm plug of omental fat (a free omentum graft) to cover the surgical site and segregate it from the diaphragm, held in place with chromic suture. I had placed 4 perimeter liver capsule clips for radiographic localization.
Indications: has a 1.8 cm mass in the dome of the right liver, segment 7 with biopsy benign but suspected sampling error. There has been a modest increase in CEA that the concern is a delayed liver metastasis. He presents for diagnostic (therapeutic) excision.
*
Description of Procedure: In the supine position with appropriate monitoring he received general anesthesia with IV antibiotic. Arterial line was placed. He is rolled to the partial left lateral decubitus position and supported with arm board and beanbag. The right chest and flank and abdomen to the midline or prepped with chlorhexidine and draped after 3 minutes. I initiate the incision through a 8 cm right subcostal oblique incision, he has a narrow costal margin. The external oblique and internal oblique and transversus abdominis are open under vision, to the rectus sheath medially. With a hand introduced I can palpate the nodule and extend the incision slightly medially and then laterally around the curve of the costal margin. An upper hand retractor is placed, the liver is explored visually and manually with no palpable mass other than described. The gallbladder is flaccid. The porta hepatis has no overtly palpable nodes. With the liver retracted anteriorly and medially, the lateral diaphragmatic attachments are released and then continued upward toward the central liver without exposing the inferior vena cava. Then using moistened laparotomy pads, the liver is elevated and a second upperhand retractor placed that we can look directly down on the lesion. We then used intraoperative sonogram identifying veins, total vein is recognized with hyperechoic surface, more deep and will not be in jeopardy. I create a circumferential trough using cautery hook, about 1.5 cm margins around the mass, final dimensions about 5 cm. This is deepened to about 1 cm and then using the Harmonic ACE, medial to lateral amputation is completed with hook cautery used to remove the remainder of the base and lateral component submitted in a separate container. With this last maneuver, the hot cautery hook penetrates my left index finger glove and penetrates my skin. The hook is discarded, gloves are exchanged and the operation is completed.
*
Peripheral hemostasis is secured with the Harmonic ACE and undermine the depth with horizontal mattress compressive 0 chromic suture, and I placed fibrillar before tying and there is no active bleeding at conclusion. We will place a dry laparotomy pad.
*
I now elevate the right colon and separate the omentum, I try to leave the pedicle laterally but it is too thin and fractures and now this is a free omental specimen. Rather than release the abdomen, I can create a free omental plug using 5 x 4 x 2 cm overlying the surgical bed held posteriorly and anteriorly with chromic suture and this will segregate the surgical bed from the diaphragm. We then assure complete hemostasis, remove all laparotomy pads which are accounted for. We use 20 mL diluted Exparel (1:1) injected in the peritoneum layer near the lower border of upper subcostal flap and the remainder laterally in the interfascial planes between the transversus abdominis, internal and external oblique. The incision is then closed with 0 PDS suture anchored laterally and tied centrally, the deep layer collects peritoneum, transversus abdominis and internal oblique and its fascia, carried laterally to the posterior sheath. The superficial layer anchors the anterior sheath medially and the external oblique fascia and muscle taking small purchase of underlying tissue along the way to close dead space. The incision is irrigated and skin reapproximated with running 4-0 subcuticular suture. Prineo Cranial dermal glue mesh is applied. Dressings are applied. Orogastric tube and Foley catheter are removed. He is awakened and exudate in the operating suite transported to PACU. There were no intraoperative complications
CPT Code: Procedures:
* LIVER RESECTION
* INTRAOPERATIVE LIVER SONOGRAM
*
*
ICD-10 : Post-Op Diagnosis Codes:
* Liver metastases (HCC) [C78.7]
*
Findings: After releasing the triangular ligament and diaphragmatic attachments of the right liver, with pads elevating the mobilize right liver, anterior exposure of the palpable mass is good with directed sonogram showing a venous outflow slightly inferior and medial. A trough is made surrounding the identified mass, about 1.5 cm margins, deepened about 1 cm with hook cautery and the mass specimen elevated from medial to lateral using Harmonic ACE. The ergometry design of this Harmonic instrument is awkward, as I come from medial to lateral I have bleeding as expected but the specimen fractures and I can palpate proximity of tumor with the deep margin and I quickly amputate and then removed the remainder of the scored posterior lateral component, quickly removing with hook cautery. Blood loss is about 100-150 mL through this and I hemostatically closed with 3 horizontally placed 0 chromic sutures on a liver needle. No other liver lesions are identified. I mobilize the right colic omentum but the remainder the omentum is tethered to the lower midline incision and cannot be easily mobilized without extending the incision, so I used a 5 x 4 x 2 cm plug of omental fat (a free omentum graft) to cover the surgical site and segregate it from the diaphragm, held in place with chromic suture. I had placed 4 perimeter liver capsule clips for radiographic localization.
Indications: has a 1.8 cm mass in the dome of the right liver, segment 7 with biopsy benign but suspected sampling error. There has been a modest increase in CEA that the concern is a delayed liver metastasis. He presents for diagnostic (therapeutic) excision.
*
Description of Procedure: In the supine position with appropriate monitoring he received general anesthesia with IV antibiotic. Arterial line was placed. He is rolled to the partial left lateral decubitus position and supported with arm board and beanbag. The right chest and flank and abdomen to the midline or prepped with chlorhexidine and draped after 3 minutes. I initiate the incision through a 8 cm right subcostal oblique incision, he has a narrow costal margin. The external oblique and internal oblique and transversus abdominis are open under vision, to the rectus sheath medially. With a hand introduced I can palpate the nodule and extend the incision slightly medially and then laterally around the curve of the costal margin. An upper hand retractor is placed, the liver is explored visually and manually with no palpable mass other than described. The gallbladder is flaccid. The porta hepatis has no overtly palpable nodes. With the liver retracted anteriorly and medially, the lateral diaphragmatic attachments are released and then continued upward toward the central liver without exposing the inferior vena cava. Then using moistened laparotomy pads, the liver is elevated and a second upperhand retractor placed that we can look directly down on the lesion. We then used intraoperative sonogram identifying veins, total vein is recognized with hyperechoic surface, more deep and will not be in jeopardy. I create a circumferential trough using cautery hook, about 1.5 cm margins around the mass, final dimensions about 5 cm. This is deepened to about 1 cm and then using the Harmonic ACE, medial to lateral amputation is completed with hook cautery used to remove the remainder of the base and lateral component submitted in a separate container. With this last maneuver, the hot cautery hook penetrates my left index finger glove and penetrates my skin. The hook is discarded, gloves are exchanged and the operation is completed.
*
Peripheral hemostasis is secured with the Harmonic ACE and undermine the depth with horizontal mattress compressive 0 chromic suture, and I placed fibrillar before tying and there is no active bleeding at conclusion. We will place a dry laparotomy pad.
*
I now elevate the right colon and separate the omentum, I try to leave the pedicle laterally but it is too thin and fractures and now this is a free omental specimen. Rather than release the abdomen, I can create a free omental plug using 5 x 4 x 2 cm overlying the surgical bed held posteriorly and anteriorly with chromic suture and this will segregate the surgical bed from the diaphragm. We then assure complete hemostasis, remove all laparotomy pads which are accounted for. We use 20 mL diluted Exparel (1:1) injected in the peritoneum layer near the lower border of upper subcostal flap and the remainder laterally in the interfascial planes between the transversus abdominis, internal and external oblique. The incision is then closed with 0 PDS suture anchored laterally and tied centrally, the deep layer collects peritoneum, transversus abdominis and internal oblique and its fascia, carried laterally to the posterior sheath. The superficial layer anchors the anterior sheath medially and the external oblique fascia and muscle taking small purchase of underlying tissue along the way to close dead space. The incision is irrigated and skin reapproximated with running 4-0 subcuticular suture. Prineo Cranial dermal glue mesh is applied. Dressings are applied. Orogastric tube and Foley catheter are removed. He is awakened and exudate in the operating suite transported to PACU. There were no intraoperative complications