Cmkuhlmey
New
Good morning, The following case was submitted w CPT codes 43840 and 49905. I don't believe the documentation is sufficient to bill a flap. Thoughts?
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed on the operating table
in supine position. After appropriate anesthesia, abdomen was prepped and
draped in standard sterile surgical fashion. Time-out was performed and all
preoperative protocols were observed. With this done, a midline incision was
made after a Foley catheter was placed, and this was carried down through the
skin and subcutaneous tissue into the abdominal cavity and this was carried
through her old incision. Upon entrance into the abdominal cavity, we were
greeted with murky fluid, consistent with upper GI/gastric perforation.
With this identified, we then placed a Bookwalter retractor and began
exploring her abdominal cavity. I basically followed the omentum up to the
previous anastomotic ulcer repair that was done in 10/2019. This showed a
re-perforation at the exact same site. The omentum was removed from the area.
The ulcer was easily identified. The edges of the ulcer were biopsied and
sent for pathologic analysis, permanent only, and the ulcer was then
reapproximated using interrupted 3-0 Vicryl vertical mattress sutures and this
provided very satisfactory closure. A 2nd layer of sutures was then used to
close over the defect with a Lembert providing a 2-layer closure. The omentum
was then tacked into the area as well, and this provided very satisfactory
closure of the defect and no evidence of leaking.
With this completed, we then inspected the area for hemostasis. Abdominal
survey was performed. Appendix was normal. Liver was normal. Gallbladder
was normal. Remainder of abdominal survey was unremarkable. The abdomen was
then irrigated with 3 L of normal saline, which was removed by suction
aspiration as best as possible. After the completion of the irrigation, we
then re-examined the area of the anastomosis and omental patch, and this
showed no bleeding. Arista powder was applied to the area, as was some minor
cautery of the omental tongue. With this completed, the abdomen was then
closed using a running #1 looped PDS. Skin was closed with staples.
Instrument, sponge and needle counts were correct.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed on the operating table
in supine position. After appropriate anesthesia, abdomen was prepped and
draped in standard sterile surgical fashion. Time-out was performed and all
preoperative protocols were observed. With this done, a midline incision was
made after a Foley catheter was placed, and this was carried down through the
skin and subcutaneous tissue into the abdominal cavity and this was carried
through her old incision. Upon entrance into the abdominal cavity, we were
greeted with murky fluid, consistent with upper GI/gastric perforation.
With this identified, we then placed a Bookwalter retractor and began
exploring her abdominal cavity. I basically followed the omentum up to the
previous anastomotic ulcer repair that was done in 10/2019. This showed a
re-perforation at the exact same site. The omentum was removed from the area.
The ulcer was easily identified. The edges of the ulcer were biopsied and
sent for pathologic analysis, permanent only, and the ulcer was then
reapproximated using interrupted 3-0 Vicryl vertical mattress sutures and this
provided very satisfactory closure. A 2nd layer of sutures was then used to
close over the defect with a Lembert providing a 2-layer closure. The omentum
was then tacked into the area as well, and this provided very satisfactory
closure of the defect and no evidence of leaking.
With this completed, we then inspected the area for hemostasis. Abdominal
survey was performed. Appendix was normal. Liver was normal. Gallbladder
was normal. Remainder of abdominal survey was unremarkable. The abdomen was
then irrigated with 3 L of normal saline, which was removed by suction
aspiration as best as possible. After the completion of the irrigation, we
then re-examined the area of the anastomosis and omental patch, and this
showed no bleeding. Arista powder was applied to the area, as was some minor
cautery of the omental tongue. With this completed, the abdomen was then
closed using a running #1 looped PDS. Skin was closed with staples.
Instrument, sponge and needle counts were correct.