49320 or 49321?

Alfaro33

Contributor
Messages
19
Best answers
0
MD coded 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
I'm thinking 49321 Laparoscopy, surgical; with biopsy (single or multiple)

Thoughts?


Operation
1. Exploratory laparotomy
2. Debridement and resection of pancreatic tail
3. Diagnostic laparoscopy
4. Splenectomy
5. Percutaneous biopsy of colonic mesenteric mass
6. Drain placement
7. Omentectomy

Anesthesia
geta

Technique
After the appropriate preop and consent was obtained, the patient was taken to the operating room and laid supine on the operating room table with arms out. They were prepped and draped in the usual sterile fashion. After a time-out was performed we made a curvilinear infraumbilical incision and dissected down the umbilical stalk to the splitting of the right FA. We then using 11 blade incised the stalk and used a Kelly clamp to enter the abdominal cavity. We placed a 0 Vicryl U-stitch and introduced a his son port. We insufflated the abdominal cavity opening pressure was less than 5 mmHg we insufflated to approximately 15 mmHg. The patient was placed in reverse Trendelenburg. We then placed 3 5 mm ports in the usual position for laparoscopic distal pancreatectomy. We were immediately met with extensive adhesions. We mobilized the colon as best we could we took down the splenic flexure however the mid to distal portion of the transverse colon and its mesentery were firmly adhered to the posterior aspect of the stomach and pancreas. We were a ventrally able to create a plane between the colonic mesentery and stomach to identify the pancreas we created a retropancreatic tunnel medial to the SMA and portal vein we were able to get a blue loaded stapler echelon 65 through it and stapled it off. We oversewed with a 2-0 PDS. The distal portion of the pancreas was grossly adherent to the spleen itself which required to come out as part of the operation. We took the short gastrics with EnSeal and silk ties and then followed it around and fully mobilized the spleen up into the air and came across its hilum with a white load echelon stapler again. Next we finished at removing and mobilizing the the distal pancreas and ultimately removed the specimen in its entirety. We also excised a fair amount of omentum as part of this operation as it was also grossly adhered to the pancreas and required excision in order to get the pancreas out. After all the specimens were handed off we further debrided the area as there was a pseudo cystic structure there was also a small amount of left adrenal gland and our specimen which was handed off as specimen as well. We washed out the abdomen with over 5 L of fluid and irrigated. Next we made we sure we had good hemostasis which we did. We placed 2-19 round JP drains 1 in the left upper quadrant and a 2nd in the pancreatic bed. We did closely examine the stomach and colonic mesentery and colon and ran the bowel at the splenic flexure of the colon hilum was significantly beaten up during this operation for which we were concerned and that is why we left the 2nd drain in however there were no tears, it did not appear to be threatened but did have a few small bruises on it. We ran the bowel in its entirety there was no evidence of injury. The stomach also had no evidence of injury. We closed the abdominal cavity with a 1. PDS looped. For the fascia, next we used 4-0 Vicryl for the subcu fat and a 5 0 running Monocryl for the skin. JP drains were secured in place by 3-0 nylon stitches. The incision was then dressed with a dry sterile dressing Mastisol and Steri-Strips as well. All counts were correct x2. I was scrubbed and present for the entirety of the procedure. There were no apparent complications.

Estimated Blood Loss
600 mL

Findings
Colon and colonic mesentery as well as stomach grossly adhered to the pancreas likely from multiple episodes of pancreatitis as well as a findings of a pseudocyst. The distal transverse colon appeared viable but had been bruised during the freeing from the distal pancreas

Specimen(s)
Pancreas spleen partial left adrenal gland omentum and some colonic mesentery
Colonic mesenteric mass which was biopsied during the laparoscopic phase of the operation showed no evidence of malignancy on fast frozen
 

csperoni

True Blue
Messages
1,225
Location
Selden
Best answers
3
If 49320 or 49321 are the only codes you are thinking of using, it seems to me you are missing out on a lot of what was done.
My 30 second glance of this (and not my area of expertise) looks like they planned a laparoscopic, but needed to convert to open. When that occurs, you bill how the surgery was completed (open) including dx Z53.31. Depending on what procedure codes you come up with, modifier -22 MAY be warranted I would recommend you indicate the full coding you are considering for additional input.
 
Top