coder25
Guru
The patient has SBO. Surgeon performed an exploratory laparotomy and small bowel enterotomy with removal of a single gallstone.
I was looking at 44615, but they do not talk about removing anything. I also looked at 44020 which is enterotomy with removal of foreign body. Would the gallstone constitute as the foreign body? Is the code I should be using?
Here's the report:
A lower midline incision was made incorporating the patient's previous DPL incision. Subq tissues were dissected down to the fascia. The fascia was sharply entered. The peritoneum was grasped with two hemostats and lifted anteriorly. Metzenbaum scissors were used to enter the peritoneal cavity. The SB was then brought out through the wound and appeared viable. It was then followed proximally to the ligament of Treitz and no adhesions or masses were found. It was then followed back towards the terminal ileum. The SB was noted to be mildly distended. Shortly prior to the terminal ileum, a hard mass was palpated in the SB. An enterotomy was therefore performed in a longitudinal fashion and the gallstone was removed from the SB through the enterotomy. It was then reapproximated using #1 PDS sutures in a running fashion as well as 2-0 Vicryl sutures in interuppted fashion as internal retentions.
Thanks for you help!
Peggy
I was looking at 44615, but they do not talk about removing anything. I also looked at 44020 which is enterotomy with removal of foreign body. Would the gallstone constitute as the foreign body? Is the code I should be using?
Here's the report:
A lower midline incision was made incorporating the patient's previous DPL incision. Subq tissues were dissected down to the fascia. The fascia was sharply entered. The peritoneum was grasped with two hemostats and lifted anteriorly. Metzenbaum scissors were used to enter the peritoneal cavity. The SB was then brought out through the wound and appeared viable. It was then followed proximally to the ligament of Treitz and no adhesions or masses were found. It was then followed back towards the terminal ileum. The SB was noted to be mildly distended. Shortly prior to the terminal ileum, a hard mass was palpated in the SB. An enterotomy was therefore performed in a longitudinal fashion and the gallstone was removed from the SB through the enterotomy. It was then reapproximated using #1 PDS sutures in a running fashion as well as 2-0 Vicryl sutures in interuppted fashion as internal retentions.
Thanks for you help!
Peggy