RainyDaze
Networker
I have attached a op report I need help coding. Doctor was to repair a ventral hernia, however when she got in there there was none. She explored then closed with a layered closure. It doesn't look like she debrided tissue. Is there a code I can use for exploration? Should I just code for intermediate closure. I'm not sure on this one.
Thanks for your help,
Lori
PREOPERATIVE DIAGNOSIS: Ventral incisional hernia.
POSTOPERATIVE DIAGNOSIS: No ventral incisional hernia identified.
PROCEDURE: Subcutaneous exploration of the area of concern.
TYPE OF ANESTHESIA: General.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a 35-year-old white female who at age 20, underwent open splenectomy through a long midline incision. Over the last several months, she has developed an increasingly painful intermittent bulge at the mid epigastric region just at the level of her xiphoid. She was unable to produce the mass on exam in my office. She again was unable to produce the mass here in pre-surgery. However, the area of her concern. She had declined additional workup previously.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine on the operating room table where general endotracheal anesthesia was provided. The abdomen was prepped and draped in the usual sterile fashion. The most inferior aspect of the old scar in the midepigastric region was incised after local anesthetic was injected. The incision was carried on down into the subcutaneous tissues right down onto fascia. The fascia was cleared widely least 3 cm bilaterally on either side and an area clearance of at least 6-8 cm superiorly to inferiorly. No defect was noted. There was no lipomatous mass or other concerns. The area was irrigated. Local anesthetic was infiltrated into the deep surrounding tissues. I did go ahead and bridge the rectus musculature to midline using #0 Ethibond suture. The deeper subcutaneous tissues were reapproximated using #0 Vicryl suture, and the subcutaneous tissues were reapproximated using 3-0 Vicryl suture. The skin was closed using a running 4-0 Monocryl suture. Dermabond was applied for dressing. The patient was extubated and taken to recovery room in good condition. There were no complications, and she tolerated the procedure very well.
We will see how the patient does postoperatively. There was concern that possibly this was a type of floating xiphoid; however, the xiphoid appeared very much intact and not mobile such that I left it alone.
Thanks for your help,
Lori
PREOPERATIVE DIAGNOSIS: Ventral incisional hernia.
POSTOPERATIVE DIAGNOSIS: No ventral incisional hernia identified.
PROCEDURE: Subcutaneous exploration of the area of concern.
TYPE OF ANESTHESIA: General.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a 35-year-old white female who at age 20, underwent open splenectomy through a long midline incision. Over the last several months, she has developed an increasingly painful intermittent bulge at the mid epigastric region just at the level of her xiphoid. She was unable to produce the mass on exam in my office. She again was unable to produce the mass here in pre-surgery. However, the area of her concern. She had declined additional workup previously.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed supine on the operating room table where general endotracheal anesthesia was provided. The abdomen was prepped and draped in the usual sterile fashion. The most inferior aspect of the old scar in the midepigastric region was incised after local anesthetic was injected. The incision was carried on down into the subcutaneous tissues right down onto fascia. The fascia was cleared widely least 3 cm bilaterally on either side and an area clearance of at least 6-8 cm superiorly to inferiorly. No defect was noted. There was no lipomatous mass or other concerns. The area was irrigated. Local anesthetic was infiltrated into the deep surrounding tissues. I did go ahead and bridge the rectus musculature to midline using #0 Ethibond suture. The deeper subcutaneous tissues were reapproximated using #0 Vicryl suture, and the subcutaneous tissues were reapproximated using 3-0 Vicryl suture. The skin was closed using a running 4-0 Monocryl suture. Dermabond was applied for dressing. The patient was extubated and taken to recovery room in good condition. There were no complications, and she tolerated the procedure very well.
We will see how the patient does postoperatively. There was concern that possibly this was a type of floating xiphoid; however, the xiphoid appeared very much intact and not mobile such that I left it alone.