l1ttle_0ne
Guru
I'm having trouble coding this operative report. I'm not sure if I should be using a partial colectomy code for the cecectomy considering that he removed so little. If anyone could give me their opinion on the codes. It would be greatly appreciated.
PREOPERATIVE DIAGNOSIS: Appendiceal/cecal "mass"
POSTOPERATIVE DIAGNOSIS: Appendiceal/cecal "mass"
PROCEDURE: Appendectomy and partial cecectomy.
ANESTHESIA: General.
INDICATIONS: This is a -year-old woman who was found on a routine screening colonoscopy in February 2013 to have a 6 x 10 mm mass at the orifice of the appendix. A CT scan was obtained in April 2013 which showed a "prominent" base of the appendix, measuring 8 mm. The next imaging was an MRI on 01/06/2014 which showed a cystic appendiceal lesion, unchanged in size.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. General anesthesia was induced. The abdomen was prepped and draped. A horizontal incision was made in the skin of the right lower quadrant at McBurney's point. This incision was carried down to the external oblique aponeurosis. The external oblique aponeurosis was opened in the direction of its fibers. The internal oblique and transversus abdominis muscles were split. The peritoneum was opened horizontally. The right lower quadrant was explored. The appendix and the cecum were delivered through the wound. The mesoappendix was taken down between clamps and ties. I then dissected all around the base of the appendix. I palpated the appendix and the cecum and I could not feel any mass. An incision was made into the cecum at the base of the appendix. Using Army-Navy retractors and a nasal speculum, I examined the mucosa of the cecum directly. I examined into the cecum as far as I could possibly see and I saw no mass. I opened the appendix up vertically from the base up to the mid portion of the appendix and I found no mass in the appendix either. I decided that I would remove the appendix along with a fairly large wedge of the base of the cecum. This was performed using one application of the GIA stapler. I removed the cecum back at least 2-3 cm from the base of the appendix with this one GIA application. The specimen was then submitted. The right lower quadrant and pelvis were irrigated with saline solution. The fascial layers were closed with interrupted and running 2-0 Vicryl sutures. The skin was closed with a running 4-0 Vicryl subcuticular suture. The wound was infiltrated with 0.5% Marcaine. A Dermabond dressing was applied. The patient tolerated the procedure well. She was awakened and transported to the recovery room in satisfactory condition. The estimated blood loss was minimal. There were no operative complications.
PREOPERATIVE DIAGNOSIS: Appendiceal/cecal "mass"
POSTOPERATIVE DIAGNOSIS: Appendiceal/cecal "mass"
PROCEDURE: Appendectomy and partial cecectomy.
ANESTHESIA: General.
INDICATIONS: This is a -year-old woman who was found on a routine screening colonoscopy in February 2013 to have a 6 x 10 mm mass at the orifice of the appendix. A CT scan was obtained in April 2013 which showed a "prominent" base of the appendix, measuring 8 mm. The next imaging was an MRI on 01/06/2014 which showed a cystic appendiceal lesion, unchanged in size.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. General anesthesia was induced. The abdomen was prepped and draped. A horizontal incision was made in the skin of the right lower quadrant at McBurney's point. This incision was carried down to the external oblique aponeurosis. The external oblique aponeurosis was opened in the direction of its fibers. The internal oblique and transversus abdominis muscles were split. The peritoneum was opened horizontally. The right lower quadrant was explored. The appendix and the cecum were delivered through the wound. The mesoappendix was taken down between clamps and ties. I then dissected all around the base of the appendix. I palpated the appendix and the cecum and I could not feel any mass. An incision was made into the cecum at the base of the appendix. Using Army-Navy retractors and a nasal speculum, I examined the mucosa of the cecum directly. I examined into the cecum as far as I could possibly see and I saw no mass. I opened the appendix up vertically from the base up to the mid portion of the appendix and I found no mass in the appendix either. I decided that I would remove the appendix along with a fairly large wedge of the base of the cecum. This was performed using one application of the GIA stapler. I removed the cecum back at least 2-3 cm from the base of the appendix with this one GIA application. The specimen was then submitted. The right lower quadrant and pelvis were irrigated with saline solution. The fascial layers were closed with interrupted and running 2-0 Vicryl sutures. The skin was closed with a running 4-0 Vicryl subcuticular suture. The wound was infiltrated with 0.5% Marcaine. A Dermabond dressing was applied. The patient tolerated the procedure well. She was awakened and transported to the recovery room in satisfactory condition. The estimated blood loss was minimal. There were no operative complications.