NVobgynCoder
Contributor
I need help coding this Op report:
Preoperative DX: Right lower quadrant mass, possible hernia
Postoperative DX: Omental herniation right lower quadrant
Operation: Mini laparotomy with lysis of adhesions and excision of portion of the omentum
Description of Procedure: Under satisfactory general anesthesa, patient was placed in the supine position. Abdomen prepped and draped sterile field as well as the vulva and perineum. Direction was first paid to the abdominal wall and in an area of an old incision, an incision was started and extended approx 1 inch lateral to the old incision, total length of approx 3 inches. The thickened fatty tissues were grasped and dissected down until the fascia which was grasped and held and then the mass elevated. The peritoneum was entered and was noted to be a segment of omentum extending up through the incision. This was dissected free of any adhesions and then clamps placed across a portion of omentum, anthis was excised and removed after being doubly ligated. No abnormalities were noted through the incision. Peritoneum was then closed using a 2-0 Vicryl suture. The fascia was closed using #1 Vicryl suture. Subcutaneous tissues closed using 2-0 Vicryl suture and 4-0 subcuticular Dexon suture on the skin.
According to the Pathology report, the specimen was adipose tissue measuring approximately 8x4.5x0.1 cm. Their final diagnosis was benign fibroadipose tissue; 211.8
I know there isn't a code for a "Mini" laparotomy, so I was looking at the laparotomy codes and the best one I found was 49255 for an omentectomy. Would that be correct?
Any feedback would be helpful!
Thanks!
Claudia
Preoperative DX: Right lower quadrant mass, possible hernia
Postoperative DX: Omental herniation right lower quadrant
Operation: Mini laparotomy with lysis of adhesions and excision of portion of the omentum
Description of Procedure: Under satisfactory general anesthesa, patient was placed in the supine position. Abdomen prepped and draped sterile field as well as the vulva and perineum. Direction was first paid to the abdominal wall and in an area of an old incision, an incision was started and extended approx 1 inch lateral to the old incision, total length of approx 3 inches. The thickened fatty tissues were grasped and dissected down until the fascia which was grasped and held and then the mass elevated. The peritoneum was entered and was noted to be a segment of omentum extending up through the incision. This was dissected free of any adhesions and then clamps placed across a portion of omentum, anthis was excised and removed after being doubly ligated. No abnormalities were noted through the incision. Peritoneum was then closed using a 2-0 Vicryl suture. The fascia was closed using #1 Vicryl suture. Subcutaneous tissues closed using 2-0 Vicryl suture and 4-0 subcuticular Dexon suture on the skin.
According to the Pathology report, the specimen was adipose tissue measuring approximately 8x4.5x0.1 cm. Their final diagnosis was benign fibroadipose tissue; 211.8
I know there isn't a code for a "Mini" laparotomy, so I was looking at the laparotomy codes and the best one I found was 49255 for an omentectomy. Would that be correct?
Any feedback would be helpful!
Thanks!
Claudia