I have a group that says they have always billed the round cord lipoma excision with the laparoscopic inguinal hernia repair using 49650, 49659-59 compare to 55520. I think this is incorrect per the lipoma being through same incision and it is in the inguinal canal. Looking for any guidance you might have. Here is the operative report:
The patient was brought to the operating room. He was placed in asupine position. Venous compression devices were applied. Preoperativeantibiotics were given. He then underwent general endotracheal anesthesia.Both arms were tucked. The patient had a Foley catheter placed. The abdomenwas shaved, prepped, and draped in usual sterile fashion. A time-out wasperformed. A infraumbilical 8 mm incision was created with an 11 bladescalpel. Veress needle was introduced through the incision andpneumoperitoneum was successfully achieved with a pressure of 15 mmHg. Next,an 8 mm metallic robotic Optiview trocar was introduced through theperiumbilical incision utilizing a 0-degree 5 mm trocar and the intraabdominalcavity was entered under direct visualization. Intraabdominal cavity wasexplored. There was no evidence of any intraabdominal or visceral injuries.Two additional 8 mm metallic trocars were placed under direct visualization onthe left and the right side of the abdomen at the level of the periumbilicaltrocar. Next, the patient was placed on a steep Trendelenburg position. Therobotic boom was brought over the patient. The periumbilical port was dockedto the robotic arm, targeting towards the pelvis was performed. The remainingother 2 trocars were docked to the robot. The robotic instruments wereintroduced under direct visualization. Next, I scrub out from the sterilefield and sat on the robotic console and started the procedure. I started bygrasping the peritoneum at the level of the right anterior superior iliacspine and with robotic scissors, I started the preperitoneal space byparietalizing the peritoneum utilizing electrocautery. The peritonealincision was taken medially to the median umbilical ligament. The peritonealflap was taken down from the anterior abdominal wall with careful dissection.The preperitoneal dissection of the abdominal wall was performed in lateral tomedial fashion. The critical view of the myopectineal orifice was obtained.The round ligament was identified. This was skeletonized cauterized andtransected. The external iliac was completely dissected of the peritoneum.There was a hernia sac at the indirect hernia measuring approximately 1.5 cm.The hernia was reduced, containing fat. The iliopubic tract was identified.Cooper ligament was identified. The dissection of the preperitoneal space wasperformed 1-2 cm towards the contralateral midline. The rectus muscles weredissected of the peritoneum. There was no evidence of any hernias in the samesite, a round ligament lipoma was reduced from the inguinal canal and excisedwith robotic scissors and sent to pathology. Next, 3DMax mesh MID large rightsided was introduced into the intraabdominal cavity. The mesh was placed atthe center of the hernia space. The mesh was tacked to the Cooper's ligament.Another 3-0 Vicryl was then was used to tack the mesh lateral to the deepinferior epigastric vessels. There was no evidence of bleeding. There wasgood hemostasis. The mesh was lying flat on the myopectineal orifice. Next,peritoneum was reattached to the anterior abdominal wall with a running 3-0V-Loc suture. Pneumoperitoneum was reduced to 5 mmHg and the gas from thepreperitoneal space was vented and pneumoperitoneum was placed again to 15mmHg, attaching the peritoneum to the anterior abdominal wall. The needleswere removed under direct visualization from the intraabdominal cavity. Therobot then was undocked. The ports were removed under direct visualization.There was no evidence of bleeding of the intraabdominal wall. Next, Iscrubbed in again to sterile field. Next, 4-0 Monocryl was utilized toapproximate the port site skin incisions. Dermabond was applied over the skinof the incisions. The patient was extubated and sent to the postanesthesiacare unit in good condition.
The patient was brought to the operating room. He was placed in asupine position. Venous compression devices were applied. Preoperativeantibiotics were given. He then underwent general endotracheal anesthesia.Both arms were tucked. The patient had a Foley catheter placed. The abdomenwas shaved, prepped, and draped in usual sterile fashion. A time-out wasperformed. A infraumbilical 8 mm incision was created with an 11 bladescalpel. Veress needle was introduced through the incision andpneumoperitoneum was successfully achieved with a pressure of 15 mmHg. Next,an 8 mm metallic robotic Optiview trocar was introduced through theperiumbilical incision utilizing a 0-degree 5 mm trocar and the intraabdominalcavity was entered under direct visualization. Intraabdominal cavity wasexplored. There was no evidence of any intraabdominal or visceral injuries.Two additional 8 mm metallic trocars were placed under direct visualization onthe left and the right side of the abdomen at the level of the periumbilicaltrocar. Next, the patient was placed on a steep Trendelenburg position. Therobotic boom was brought over the patient. The periumbilical port was dockedto the robotic arm, targeting towards the pelvis was performed. The remainingother 2 trocars were docked to the robot. The robotic instruments wereintroduced under direct visualization. Next, I scrub out from the sterilefield and sat on the robotic console and started the procedure. I started bygrasping the peritoneum at the level of the right anterior superior iliacspine and with robotic scissors, I started the preperitoneal space byparietalizing the peritoneum utilizing electrocautery. The peritonealincision was taken medially to the median umbilical ligament. The peritonealflap was taken down from the anterior abdominal wall with careful dissection.The preperitoneal dissection of the abdominal wall was performed in lateral tomedial fashion. The critical view of the myopectineal orifice was obtained.The round ligament was identified. This was skeletonized cauterized andtransected. The external iliac was completely dissected of the peritoneum.There was a hernia sac at the indirect hernia measuring approximately 1.5 cm.The hernia was reduced, containing fat. The iliopubic tract was identified.Cooper ligament was identified. The dissection of the preperitoneal space wasperformed 1-2 cm towards the contralateral midline. The rectus muscles weredissected of the peritoneum. There was no evidence of any hernias in the samesite, a round ligament lipoma was reduced from the inguinal canal and excisedwith robotic scissors and sent to pathology. Next, 3DMax mesh MID large rightsided was introduced into the intraabdominal cavity. The mesh was placed atthe center of the hernia space. The mesh was tacked to the Cooper's ligament.Another 3-0 Vicryl was then was used to tack the mesh lateral to the deepinferior epigastric vessels. There was no evidence of bleeding. There wasgood hemostasis. The mesh was lying flat on the myopectineal orifice. Next,peritoneum was reattached to the anterior abdominal wall with a running 3-0V-Loc suture. Pneumoperitoneum was reduced to 5 mmHg and the gas from thepreperitoneal space was vented and pneumoperitoneum was placed again to 15mmHg, attaching the peritoneum to the anterior abdominal wall. The needleswere removed under direct visualization from the intraabdominal cavity. Therobot then was undocked. The ports were removed under direct visualization.There was no evidence of bleeding of the intraabdominal wall. Next, Iscrubbed in again to sterile field. Next, 4-0 Monocryl was utilized toapproximate the port site skin incisions. Dermabond was applied over the skinof the incisions. The patient was extubated and sent to the postanesthesiacare unit in good condition.