Question.. I code for a urologist and he came in at the end of the surgery below to place a foley catheter. The note below was dictated by the primary surgeon (not my urologist) and states "Please see urologist's operative note" for description of the cath placement. My provider wants to bill for the difficult cath placement without dictating his own note. He says what the other doctor dictated below is what was done. I was taught that each procedure needs to be dictated separately by the physician that performed the procedure in order to bill for it. Thoughts? Thanks!!
Procedures
1. Exploratory laparotomy, lysis of adhesions
2. Appendectomy
3. Cholecystectomy with intraoperative cholangiogram
4. Abdominal washout
5. Pico placement
6. Intraoperative consult with Foley catheter placement by Dr. D******
Surgeons / Assistants
* John J C**** - Primary
* Jeffrey A D**** - Assisting (Cath placement)
* Steven C B*** - Assisting
Indications:
77 y.o. male who is having a procedure for
Small bowel obstruction (CMS/HCC) (HCC) [K56.609]
Calculus of gallbladder with biliary obstruction but without cholecystitis [K80.21]
Patient presented to the hospital with evidence of a partial small-bowel obstruction. Patient underwent evaluation including HIDA scan was found have evidence of biliary obstruction. Patient was ultimately taken to the operating room for definitive surgical intervention. Risks benefits alternatives suture were discussed the patient agreed to proceed.
Procedure Details:
Patient was taken to the operating room and placed in the supine position. General endotracheal anesthesia was administered. The patient had SCDs placed prior to induction. The patient was repositioned in the supine position with all pressure points protected. The area was prepped and draped in the normal sterile fashion. Adequate time-out was taken. Or after the patient was prepped and draped a time-out was taken. The appropriate patient, procedure, antibiotics were confirmed.
I made an initial 30 cm midline incision. Carried my dissection down to the fascia. The fascia was incised sharply. Upon entrance into the abdominal cavity there was copious amounts of murky fluid. The bowel appeared to be pink and mildly dilated. I began running the bowel from the ligament Treitz distally. As I made my way towards the ileum the bowel full did up into the right upper quadrant. The patient had adhesions to the right upper quadrant. These were taken down using LigaSure device and blunt dissection. Ultimately freed up the small bowel which resulted in a band at the level of the terminal ileum. The the bowel was viable. In elevating the cecum the appendix was noted to be gangrenous. We divided the appendiceal mesentery using a clamp and tie technique. Using the linear stapler we divided the base of the cecum preserving the ileocecal valve. With the bowel now freed up we ran the bowel again. No other abnormalities were appreciated to the small bowel. The staple line was intact at the level of the cecum. No bleeding was identified.
We then inspected the gallbladder. Gallbladder was grossly abnormal. There was evidence of acute cholecystitis with hydrops. As I palpated the gallbladder there was clearly a stone noted within the cystic duct. Decision was made to proceed with cholecystectomy. We extended our incision by 5 cm. We are able to expose the right upper quadrant. We were able to identify the infundibulum. We meticulously dissected out the infundibulum. There was an anterior cystic artery. We placed 2 clips proximally 1 distally and it ligated. The infundibulum of the gallbladder was grossly abnormal. The cystic duct was difficult to identify. We made a decision to ligate the gallbladder at the level of the infundibulum. In doing so we then were able to remove the gallbladder from the gallbladder bed fossa. There was a fair amount of oozing from the gallbladder bed fossa. Using the argon beam we were able to control the bleeding. Once we had the gallbladder bed hemostatic we turned our attention to the ligated part of the infundibulum. It was difficult to clearly identify the anatomy. There was bile emanating from the stump and gravel appreciated. A decision was made to perform intraoperative cholangiogram. Please see Dr. B****** operative note.
With the cholangiogram performed, a cystic duct taking off from the right hepatic duct was identified. There was flow from the cystic duct into the duodenum. No evidence of choledocholithiasis was noted. Once the cholangiogram was performed we then made a decision to close the cystic duct using interrupted 4-0 Prolene suture. The interrupted 4-0 Prolene suture allowed for apposition of the tissues. Placed a clip to the tissue as well. We irrigated the area well. No evidence of bile leak was identified.
We then irrigated the abdomen with 3 L antibiotic soak solution. A piece of snow was placed at the level of the gallbladder bed fossa and overlying the stump. The decision was made to leave a 10 French flat drain in the right upper quadrant. We laid omentum over the repair of the cystic duct. The drain was placed underneath the right lobe of the liver over the omentum. Neck was brought out through the right lower quadrant.
With the abdomen now irrigated to clear, drain in place we again inspected the small bowel. No abnormalities were appreciated. The NG tube was noted to be in the stomach. The abdomen was hemostatic. A E lap count was noted be correct. At this point decision was made to close the abdomen. Using looped 1. PDS suture I reapproximated the fascia. We then irrigated the midline wound with Irrisept. Dermis epidermis reapproximated using 3 0 Monocryl. A pico dressing was placed to the midline wound. The drain was secured using 3 0 nylon suture.
Intraoperatively we asked Dr. D***** to place a Foley catheter. The circulator at the beginning the case was unable to pass a catheter. As the case progressed patient required a Foley catheter. Patient was found have evidence of hypospadia and the coude catheter was successfully placed. Please see Dr. D**** operative note
Patient tolerated the procedure well. All instrument lap counts were noted be correct.
Findings: Small-bowel obstruction secondary to adhesion
Gangrenous appendicitis
Hydrops of the gallbladder with cystic duct stone
Apparent cystic duct off the right hepatic duct
Hypospadia
Procedures
1. Exploratory laparotomy, lysis of adhesions
2. Appendectomy
3. Cholecystectomy with intraoperative cholangiogram
4. Abdominal washout
5. Pico placement
6. Intraoperative consult with Foley catheter placement by Dr. D******
Surgeons / Assistants
* John J C**** - Primary
* Jeffrey A D**** - Assisting (Cath placement)
* Steven C B*** - Assisting
Indications:
77 y.o. male who is having a procedure for
Small bowel obstruction (CMS/HCC) (HCC) [K56.609]
Calculus of gallbladder with biliary obstruction but without cholecystitis [K80.21]
Patient presented to the hospital with evidence of a partial small-bowel obstruction. Patient underwent evaluation including HIDA scan was found have evidence of biliary obstruction. Patient was ultimately taken to the operating room for definitive surgical intervention. Risks benefits alternatives suture were discussed the patient agreed to proceed.
Procedure Details:
Patient was taken to the operating room and placed in the supine position. General endotracheal anesthesia was administered. The patient had SCDs placed prior to induction. The patient was repositioned in the supine position with all pressure points protected. The area was prepped and draped in the normal sterile fashion. Adequate time-out was taken. Or after the patient was prepped and draped a time-out was taken. The appropriate patient, procedure, antibiotics were confirmed.
I made an initial 30 cm midline incision. Carried my dissection down to the fascia. The fascia was incised sharply. Upon entrance into the abdominal cavity there was copious amounts of murky fluid. The bowel appeared to be pink and mildly dilated. I began running the bowel from the ligament Treitz distally. As I made my way towards the ileum the bowel full did up into the right upper quadrant. The patient had adhesions to the right upper quadrant. These were taken down using LigaSure device and blunt dissection. Ultimately freed up the small bowel which resulted in a band at the level of the terminal ileum. The the bowel was viable. In elevating the cecum the appendix was noted to be gangrenous. We divided the appendiceal mesentery using a clamp and tie technique. Using the linear stapler we divided the base of the cecum preserving the ileocecal valve. With the bowel now freed up we ran the bowel again. No other abnormalities were appreciated to the small bowel. The staple line was intact at the level of the cecum. No bleeding was identified.
We then inspected the gallbladder. Gallbladder was grossly abnormal. There was evidence of acute cholecystitis with hydrops. As I palpated the gallbladder there was clearly a stone noted within the cystic duct. Decision was made to proceed with cholecystectomy. We extended our incision by 5 cm. We are able to expose the right upper quadrant. We were able to identify the infundibulum. We meticulously dissected out the infundibulum. There was an anterior cystic artery. We placed 2 clips proximally 1 distally and it ligated. The infundibulum of the gallbladder was grossly abnormal. The cystic duct was difficult to identify. We made a decision to ligate the gallbladder at the level of the infundibulum. In doing so we then were able to remove the gallbladder from the gallbladder bed fossa. There was a fair amount of oozing from the gallbladder bed fossa. Using the argon beam we were able to control the bleeding. Once we had the gallbladder bed hemostatic we turned our attention to the ligated part of the infundibulum. It was difficult to clearly identify the anatomy. There was bile emanating from the stump and gravel appreciated. A decision was made to perform intraoperative cholangiogram. Please see Dr. B****** operative note.
With the cholangiogram performed, a cystic duct taking off from the right hepatic duct was identified. There was flow from the cystic duct into the duodenum. No evidence of choledocholithiasis was noted. Once the cholangiogram was performed we then made a decision to close the cystic duct using interrupted 4-0 Prolene suture. The interrupted 4-0 Prolene suture allowed for apposition of the tissues. Placed a clip to the tissue as well. We irrigated the area well. No evidence of bile leak was identified.
We then irrigated the abdomen with 3 L antibiotic soak solution. A piece of snow was placed at the level of the gallbladder bed fossa and overlying the stump. The decision was made to leave a 10 French flat drain in the right upper quadrant. We laid omentum over the repair of the cystic duct. The drain was placed underneath the right lobe of the liver over the omentum. Neck was brought out through the right lower quadrant.
With the abdomen now irrigated to clear, drain in place we again inspected the small bowel. No abnormalities were appreciated. The NG tube was noted to be in the stomach. The abdomen was hemostatic. A E lap count was noted be correct. At this point decision was made to close the abdomen. Using looped 1. PDS suture I reapproximated the fascia. We then irrigated the midline wound with Irrisept. Dermis epidermis reapproximated using 3 0 Monocryl. A pico dressing was placed to the midline wound. The drain was secured using 3 0 nylon suture.
Intraoperatively we asked Dr. D***** to place a Foley catheter. The circulator at the beginning the case was unable to pass a catheter. As the case progressed patient required a Foley catheter. Patient was found have evidence of hypospadia and the coude catheter was successfully placed. Please see Dr. D**** operative note
Patient tolerated the procedure well. All instrument lap counts were noted be correct.
Findings: Small-bowel obstruction secondary to adhesion
Gangrenous appendicitis
Hydrops of the gallbladder with cystic duct stone
Apparent cystic duct off the right hepatic duct
Hypospadia