rockylopez
Networker
Hello Everyone. I wanted to ask for coding advice. I am gearing towards cpt code 49000 but wanted to confirm. Any help is appreciated.
Primary Procedure: LAPAROTOMY EXPLORATORY RSO
Pre-procedure diagnosis:
Right Hemorrhagic Ovarian Cyst
Post-procedure diagnosis: same as pre procedure dx
Procedures performed:
Open RSO
Anesthesia: general anesthesia
Findings:
17 cm hemorrhagic right ovarian cyst, ruptured on removal, full of clots and free blood;
Normal uterus, remnants of left tube, left ovary
Complications: none
Estimated blood loss in ml's: 300 (existing losses)
Specimens removed/altered: Right tube and ovary
Drain(s): Foley Catheter Placed
Tube(s): none
Implant(s): none
Approach: open
Counts:
Sponge count: correct
Informed consent was obtained and the patient was taken to the operating room where she underwent general anesthesia without difficulty. She was prepared in the supine position with a Foley catheter to drainage and prepped and draped in usual fashion. A midline vertical lower abdominal incision was performed and carried through the underlying layers with a knife. The muscles and the peritoneum were divided bluntly with a hemostat and the incision was extended superiorly and inferiorly. A small amount of blood was encountered in the pelvis. The uterus, left tube and ovary were within normal limits with the exception of a mid-ampullary defect in the left tube consistent with h/o BTL.
A sample of the peritoneal fluid/blood was taken for cytology.
The ovarian mass was located in the mid to left upper quadrants. It was attached via a large pedicle but other than crossing the midline did not appear significantly torsed. On attempts to bring the mass to the incision, the mass ruptured extruding blood and organized clots. This decreased the size of the ovary, which allowed it to be brought through the incision.
The pedicle was clamped inferior to the ovary but above the tube. The ovary was then cut from its attachment and taken from the field. On further inspection the pedicle was approximately 5 to 6 cm wide however narrowed considerably proximal to the tube. For this reason an additional clamp was placed at this site and the tubal specimen was removed as well.
The pedicle was first affixed with a free tie with silk. An additional tie was placed distal to that tie using 0 Vicryl with a fore and after fixation suture. The pedicle was inspected and noted to be hemostatic.
An O'Sullivan retractor was placed.
At this point the pelvis was extensively irrigated including placing the patient in reverse Trendelenburg to facilitate evacuation of blood and clots from the upper abdomen. After multiple rounds of irrigation, the pedicle was reinspected and no further accumulation of blood was noted in the pelvis.
The retractor was removed. The muscles the peritoneum and the fascia were closed in the midline and an en bloc closure using 0 looped PDS. 2 sutures were begun superiorly and inferiorly and tied at the approximate halfway point of the incision. The subcutaneous tissues were irrigated and noted to be hemostatic. This layer was reapproximated using 2-0 Vicryl with interrupted sutures. The skin incision was closed with staples and a sterile dressing was applied.
Primary Procedure: LAPAROTOMY EXPLORATORY RSO
Pre-procedure diagnosis:
Right Hemorrhagic Ovarian Cyst
Post-procedure diagnosis: same as pre procedure dx
Procedures performed:
Open RSO
Anesthesia: general anesthesia
Findings:
17 cm hemorrhagic right ovarian cyst, ruptured on removal, full of clots and free blood;
Normal uterus, remnants of left tube, left ovary
Complications: none
Estimated blood loss in ml's: 300 (existing losses)
Specimens removed/altered: Right tube and ovary
Drain(s): Foley Catheter Placed
Tube(s): none
Implant(s): none
Approach: open
Counts:
Sponge count: correct
Informed consent was obtained and the patient was taken to the operating room where she underwent general anesthesia without difficulty. She was prepared in the supine position with a Foley catheter to drainage and prepped and draped in usual fashion. A midline vertical lower abdominal incision was performed and carried through the underlying layers with a knife. The muscles and the peritoneum were divided bluntly with a hemostat and the incision was extended superiorly and inferiorly. A small amount of blood was encountered in the pelvis. The uterus, left tube and ovary were within normal limits with the exception of a mid-ampullary defect in the left tube consistent with h/o BTL.
A sample of the peritoneal fluid/blood was taken for cytology.
The ovarian mass was located in the mid to left upper quadrants. It was attached via a large pedicle but other than crossing the midline did not appear significantly torsed. On attempts to bring the mass to the incision, the mass ruptured extruding blood and organized clots. This decreased the size of the ovary, which allowed it to be brought through the incision.
The pedicle was clamped inferior to the ovary but above the tube. The ovary was then cut from its attachment and taken from the field. On further inspection the pedicle was approximately 5 to 6 cm wide however narrowed considerably proximal to the tube. For this reason an additional clamp was placed at this site and the tubal specimen was removed as well.
The pedicle was first affixed with a free tie with silk. An additional tie was placed distal to that tie using 0 Vicryl with a fore and after fixation suture. The pedicle was inspected and noted to be hemostatic.
An O'Sullivan retractor was placed.
At this point the pelvis was extensively irrigated including placing the patient in reverse Trendelenburg to facilitate evacuation of blood and clots from the upper abdomen. After multiple rounds of irrigation, the pedicle was reinspected and no further accumulation of blood was noted in the pelvis.
The retractor was removed. The muscles the peritoneum and the fascia were closed in the midline and an en bloc closure using 0 looped PDS. 2 sutures were begun superiorly and inferiorly and tied at the approximate halfway point of the incision. The subcutaneous tissues were irrigated and noted to be hemostatic. This layer was reapproximated using 2-0 Vicryl with interrupted sutures. The skin incision was closed with staples and a sterile dressing was applied.
