I was wondering if anyone had input on which of these codes would be more appropriate in this case. Must I use 38102 or can 38100 be billed out with mod 59 secondary to 44120 in this case?
PREOP DX: Ruptured Spleen
POSTOP DX:
1. Splenic capsule rupture
2. Small bowel mass
PROCEDURES PERFORMED:
1. Splenectomy
2. Small bowel resection.
FINDINGS AT SURGERY: Significant intraabdominal blood, as well as a ruptured spleen and small bowel tumor (pathology showed malignant).
PROCEDURE IN DETAIL: The patient was brought to the operating room after proper identification, confirmation of PARQ. After stabilization by the anesthesiologist, patient was then prepped an draped in normal sterile fashion. Midline incision was made, carried into the abdominal cavity. Upon entry into the abdominal cavity, left upper quadrant was packed iwth lap pads. At that point, the abdomen was then irrigated with copious amounts of normal saline and suctioned clear to clearly identify the spleen which had ruptured. It was clear that the spleen would not be salvageable since it was split down the middle, and the capsule was completely torn off. We then isolated the splenic hilum with 2 clamps. The end organ was removed, and then the splenic pedicle was then suture ligated with interrupted 0 silk suture. The abdomen was then irrigated with copious amounts of normal saline and suctioned clear. The left upper quadrant and the splenic region was inspected for hemostasis, which was well controlled. The abdomen was then explored. Due to his previous known abdominal pain, the small bowel was ran from the ligament of Treitz to the terminal ileum. We clearly identified a small bowel lesion which appeared to be a mass. It was likely the cause of his abdominal pain. Thus, a segmental resection was done. This was done by taking a wedge resection out of the mesentery with clear margins on either side of the lesion. The mesentery was then divided between Pean clamps. The proximal, distal bowel was divided with a GIA stapler, and then the specimen was removed from the table. The bowel was then reconnected by performing a side-to-side stapled end-to-end anastomosis with a GIA-75 stapler. The anastomosis was reinforced with interrupted 3-0 silkds as was the running 3-0 Vicryl. The abdomen was then irrigated with copious amounts of normal saline. The anastomosis was inspected for any signs of any vascular compromise which there was none. The abdomen was then further inspected for hemostasis, which was well controlled and the decision was made to close.
PREOP DX: Ruptured Spleen
POSTOP DX:
1. Splenic capsule rupture
2. Small bowel mass
PROCEDURES PERFORMED:
1. Splenectomy
2. Small bowel resection.
FINDINGS AT SURGERY: Significant intraabdominal blood, as well as a ruptured spleen and small bowel tumor (pathology showed malignant).
PROCEDURE IN DETAIL: The patient was brought to the operating room after proper identification, confirmation of PARQ. After stabilization by the anesthesiologist, patient was then prepped an draped in normal sterile fashion. Midline incision was made, carried into the abdominal cavity. Upon entry into the abdominal cavity, left upper quadrant was packed iwth lap pads. At that point, the abdomen was then irrigated with copious amounts of normal saline and suctioned clear to clearly identify the spleen which had ruptured. It was clear that the spleen would not be salvageable since it was split down the middle, and the capsule was completely torn off. We then isolated the splenic hilum with 2 clamps. The end organ was removed, and then the splenic pedicle was then suture ligated with interrupted 0 silk suture. The abdomen was then irrigated with copious amounts of normal saline and suctioned clear. The left upper quadrant and the splenic region was inspected for hemostasis, which was well controlled. The abdomen was then explored. Due to his previous known abdominal pain, the small bowel was ran from the ligament of Treitz to the terminal ileum. We clearly identified a small bowel lesion which appeared to be a mass. It was likely the cause of his abdominal pain. Thus, a segmental resection was done. This was done by taking a wedge resection out of the mesentery with clear margins on either side of the lesion. The mesentery was then divided between Pean clamps. The proximal, distal bowel was divided with a GIA stapler, and then the specimen was removed from the table. The bowel was then reconnected by performing a side-to-side stapled end-to-end anastomosis with a GIA-75 stapler. The anastomosis was reinforced with interrupted 3-0 silkds as was the running 3-0 Vicryl. The abdomen was then irrigated with copious amounts of normal saline. The anastomosis was inspected for any signs of any vascular compromise which there was none. The abdomen was then further inspected for hemostasis, which was well controlled and the decision was made to close.
