Wiki retroperitoneal tumor surgery

[medihedgie]

Could someone tale a gander at this and see how you would code it. My boss gave this to me because it "didn't seem right" This person is very recently postpartum

DX: Retroperitoneal tumor, large 15 cm

Procedure: Excision of retroperitoneal tumor, question is spindle cell

Findings: Large retroperitoneal tumor extremely posterior, almost attached to the spine lateral and left side of the__ pushing the renal vein and abutting the left illiac vessels and psoas muscle.

Prep...
Linea alba was incised. the peritoneum was incised the abdomen was entered and exploration reveald the liver to be small and normal with no tumor felt. Rt and Lt ovary appears to be normal. Uterus is small, normal. No ascites. Large retroperitoneal tumor found was abutting the mesesntery of the left colon. The patient also had displacement of the ligament of Treitz and displacement of the descending colon to the left. Large tumor was mobilized, the piece of fat surrounding the tumor was also removed. Bleeders were gradually controlled with 2-0 silk by litigating the vessels. No invasion of bowl no invasion of muscle.

I get 789.39 and 49205 does this seem accurate?

 

[Kelly_Mayumi]

I'd hope the tumor was removed since it doesn't specifically mention it being excised. If it was, yes I'd use 49205 but I would wait for my pathology to confirm the diagnosis.

 

[medihedgie]

Thank you Kelly!