jalbright0516
Guest
I have an op report that is for an abdominal washout with skin closure -- please see attached note.
I am struggling with the code to use because the 3m coding software is leading me to an unlisted procedure
I feel that the code is either 49000 or 49900 or even the code of 20102(but for this there was not a foreign body in the patient)
Any assistance would be appreciated.
______________________________________________________________
PREOPERATIVE DIAGNOSIS: Status post colostomy reversal. Status post
bowel resection.
POSTOPERATIVE DIAGNOSIS: Status post colostomy reversal. Status post
bowel resection.
PROCEDURE: Abdominal washout with skin closure.
BRIEF HISTORY: Ms. Graham is a 61 year old African-American female
who has recently been taken to the operating room for a perforation of
her small bowel. She had a small bowel resection and fascia closure
of her abdominal skin was open. She is being taken to the operating
room for washout of her skin.
DESCRIPTION OF PROCEDURE: The patient was taken back to the operating
theater and placed on the operative table in the supine position.
Upon proper identification at the time of the procedure, the patient
was sedated, prepped and draped in a sterile fashion. We then
irrigated one liter of normal saline of the subcutaneous tissue. We
then reapproximated the skin with the staple. In the inferior portion
of the incision, I did reapproximate the subcutaneous tissue with
interrupted 2-0 Vicryl suture. We then reapproximated the skin with
skin gun. All counts were correct. The patient was transferred to
PACU in stable condition.
I am struggling with the code to use because the 3m coding software is leading me to an unlisted procedure
I feel that the code is either 49000 or 49900 or even the code of 20102(but for this there was not a foreign body in the patient)
Any assistance would be appreciated.
______________________________________________________________
PREOPERATIVE DIAGNOSIS: Status post colostomy reversal. Status post
bowel resection.
POSTOPERATIVE DIAGNOSIS: Status post colostomy reversal. Status post
bowel resection.
PROCEDURE: Abdominal washout with skin closure.
BRIEF HISTORY: Ms. Graham is a 61 year old African-American female
who has recently been taken to the operating room for a perforation of
her small bowel. She had a small bowel resection and fascia closure
of her abdominal skin was open. She is being taken to the operating
room for washout of her skin.
DESCRIPTION OF PROCEDURE: The patient was taken back to the operating
theater and placed on the operative table in the supine position.
Upon proper identification at the time of the procedure, the patient
was sedated, prepped and draped in a sterile fashion. We then
irrigated one liter of normal saline of the subcutaneous tissue. We
then reapproximated the skin with the staple. In the inferior portion
of the incision, I did reapproximate the subcutaneous tissue with
interrupted 2-0 Vicryl suture. We then reapproximated the skin with
skin gun. All counts were correct. The patient was transferred to
PACU in stable condition.