Can someone help me with this op note? It was billed out as 50760 but was denied. I've been looking trying to find another CPT code, but I can't find anything that seems to match what was did. I'm still in school and will be taking my CPC next month. I work in charge entry and I'm trying to get this correct and billed out. Thanks in advance for any help/direction you can give me!!
PREOPERATIVE DIAGNOSIS: TRANSECTED URETER.
POSTOPERATIVE DIAGNOSIS: TRANSECTED URETER
PROCEDURE: INTRAOPERATIVE CONSULTATION AND A URETERAL REPAIR.
HISTORY OF PRESENT ILLNESS: ______ who was undergoing a
colectomy by _______ and there was an inadvertent transection of the ureter. This was
visualized immediately by _______ since he was able to see the stent. Prior to my
entering the surgical field, I asked him to go ahead and remove the colon and this was done.
DESCRIPTION OF PROCEDURE: After I scrubbed in, the proximal end of the ureter was
identified and the stent, which was approximately 5 cm above the cut portion of the ureter
was transfixed with a 4-0 Vicryl so it would not migrate any further up. The distal ureter
was also identified because it had a stent poking out from it and it was dissected free from
the surrounding tissues very carefully with a right angle and tenotomy scissors and Bovie.
The proximal stent was then grasped using Gerald forceps going up through the ureter
grasping it. It was removed without difficulty. A 6-French 24 double-J was then passed
proximally and distally without too much difficulty even though I did not have an
intraoperative stent with closed ends. 4-0 Vicryl was then used to reanastomose the ureter
in an interrupted fashion and approximately 8 sutures were placed to the reapproximation.
There was good oozing of blood flow from the edges of the ureter. After placing all the
Vicryl sutures and making sure the back wall and the front wall were completely
reapproximated. All ties were cut, the ureter was reoriented in an orthotopic fashion. We
were satisfied with the repair and I mentioned to _______ to make sure to leave a drain
in the periureteral space to make sure that any drainage would be captured. I told him that
I would remove the stent in 6-8 weeks. Case was then turned back over to _______.
PREOPERATIVE DIAGNOSIS: TRANSECTED URETER.
POSTOPERATIVE DIAGNOSIS: TRANSECTED URETER
PROCEDURE: INTRAOPERATIVE CONSULTATION AND A URETERAL REPAIR.
HISTORY OF PRESENT ILLNESS: ______ who was undergoing a
colectomy by _______ and there was an inadvertent transection of the ureter. This was
visualized immediately by _______ since he was able to see the stent. Prior to my
entering the surgical field, I asked him to go ahead and remove the colon and this was done.
DESCRIPTION OF PROCEDURE: After I scrubbed in, the proximal end of the ureter was
identified and the stent, which was approximately 5 cm above the cut portion of the ureter
was transfixed with a 4-0 Vicryl so it would not migrate any further up. The distal ureter
was also identified because it had a stent poking out from it and it was dissected free from
the surrounding tissues very carefully with a right angle and tenotomy scissors and Bovie.
The proximal stent was then grasped using Gerald forceps going up through the ureter
grasping it. It was removed without difficulty. A 6-French 24 double-J was then passed
proximally and distally without too much difficulty even though I did not have an
intraoperative stent with closed ends. 4-0 Vicryl was then used to reanastomose the ureter
in an interrupted fashion and approximately 8 sutures were placed to the reapproximation.
There was good oozing of blood flow from the edges of the ureter. After placing all the
Vicryl sutures and making sure the back wall and the front wall were completely
reapproximated. All ties were cut, the ureter was reoriented in an orthotopic fashion. We
were satisfied with the repair and I mentioned to _______ to make sure to leave a drain
in the periureteral space to make sure that any drainage would be captured. I told him that
I would remove the stent in 6-8 weeks. Case was then turned back over to _______.