Alfaro33
Networker
MD coded 32100 and 49000. Not sure about those codes and also wondering if I should be adding a reduced serviced modifier due to intraoperative death?
11/08/2020
Preoperative Diagnosis Multi-system trauma with resulting vascular injury Postoperative Diagnosis Multi-system trauma with resulting vascular injury Operation Exploration with exposure, lysis, and dissection and control of the of the thoracic aorta near the diaphragm
Exposure lysis, dissection of the abdominal aorta
Technique:
I was called in emergently to assist in the case of a patient who sustained multiple gunshot wounds with resulting vascular injury to the aorta and visceral segment. Upon entering the operating room suite 12 the patient was under general anesthesia. He had what appeared to be a clamshell and midline incision which had been performed by the trauma surgery team. There was noted to be a massive amount of of blood loss and patient's chest and abdomen were open. There appeared to be an extensive liver injury. The diaphragm was divided and the thoracic aorta was dissected out from the surrounding tissues and separated from the esophagus and a cross-clamp was placed on the thoracic aorta. After this dissection was continued distally to the visceral segment and further dissection of the abdominal aorta in this area was carried out. Throughout the process the patient was unable to sustain a perfusable cardiac rhythm and active cardiac massage and internal shocks were delivered. Secondary to no sustained perfusable cardiac rhythm despite all efforts the patient was pronounced dead by Dr. of the trauma team. Estimated Blood Loss massive Findings Large aortic injury near the visceral segment Specimen(s) none Complications intraoperative death
11/08/2020
Preoperative Diagnosis Multi-system trauma with resulting vascular injury Postoperative Diagnosis Multi-system trauma with resulting vascular injury Operation Exploration with exposure, lysis, and dissection and control of the of the thoracic aorta near the diaphragm
Exposure lysis, dissection of the abdominal aorta
Technique:
I was called in emergently to assist in the case of a patient who sustained multiple gunshot wounds with resulting vascular injury to the aorta and visceral segment. Upon entering the operating room suite 12 the patient was under general anesthesia. He had what appeared to be a clamshell and midline incision which had been performed by the trauma surgery team. There was noted to be a massive amount of of blood loss and patient's chest and abdomen were open. There appeared to be an extensive liver injury. The diaphragm was divided and the thoracic aorta was dissected out from the surrounding tissues and separated from the esophagus and a cross-clamp was placed on the thoracic aorta. After this dissection was continued distally to the visceral segment and further dissection of the abdominal aorta in this area was carried out. Throughout the process the patient was unable to sustain a perfusable cardiac rhythm and active cardiac massage and internal shocks were delivered. Secondary to no sustained perfusable cardiac rhythm despite all efforts the patient was pronounced dead by Dr. of the trauma team. Estimated Blood Loss massive Findings Large aortic injury near the visceral segment Specimen(s) none Complications intraoperative death