hsmith67
Guru
OK, my doc did:
exploratory laparotomy, greater than 2.5 hours of lysis of dense adhesions, cholecystectomy, takedown and closure of cholecystoduodenal fistula, and enterotomy with removal of gallstones from the ileum! I have to believe I can get him paid for something other than the lysis of adhesions or laparotomy! Please see below note and help is greatly appreciated. I will pick up the note once incision made:
Approximately 800 cc of ascites was evacuated from the abdomen resulting from the inflammatory process in the right upper quadrant of the abdomen. The omentum was adhesed to the anterior abdominal wall. This was lysed through a combination of blunt dissection and lysed with Metzenbaum scissors and Bovie. Once the omentum was released from the anterior abdominal wall, the incision was lengthened past the umbilicus to just proximal to the pubic symphysis. Once this was done, adhesions were found in the pelvis. Small bowel was stuck to the anterior abdominal wall, which was gently lysed with Metzenbaum scissors. Once the abdomen was full opened, a Bookwalter retractor was placed to provide adequate exposure in the abdomen. In the pelvis, there were noted to be dense adhesions of small bowel from her prior hysterectomy. The adenolysis continued for approximately 2 1/2 hours where each interloop adhesion and adhesed bowel were carefully lysed taking care not to injure the bowel. Once the bowel was mobilized from the pelvis and was brought into the operative field, the small bowel was freed from its attachement to the under surface of the omentum. The operation continued into the right upper quadrant where there was significant inflammatory reaction in the area of the duodenal bulb where the fistulous communication with the gallbladder was identified as well as several stones which could be palpated. Staying close to the gallbladder and beginning laterally, the ballbladder was bluntly dissected from its attachment to the liver on the left side. A plane between the medial side of the gallbladder was identified and using Metzenbaum scissors, this was carefully lyssed makind sure not to injure the duodenum. Once the plane was cleared, the cystic artery was identified and ligated with 3-0 silk sutures. The gallbladder wall was amputated and passed off the table as specimen. The opening in the fistulas in the small bowel was identified and defined. Allis clamps were placed on the edges of the bowel and the bowel was closed primarily with interrupted 3-0 silk sutures along its length. This area was very inflamed. The repair was then reinforced with omentum which was brought into the right upper quadrant from the transverse colon and it was then tacked in 5 positions with silk sutures completely reinforcing the repair of the duodenum. Once this was completed the abdominal cavity was then irrigated with copious amounts of bacitracin saline solution and then evacuated by suction. The bowel was palpated from the ligament of Treitz to the terminal ileum. There were gallstaones removed from the bowel through and etereotomy. There was very small soilage of ileal contents into the abodominal cavity. This was quickly cleaned up with lap sponges. This was some distance away from the ileocecal valve. The bowel was opened transversely and closed longitudinally with sile sutures and reinforced with a Lembert stitch. Of note, when the fistula was separated from the gallbladder, several large gallstones and small stones were removed, approximately 5 to 7 in total.
Soo, ideas/suggestions on how to bill this one?
Thanks,
Hunter Smith, CPC
exploratory laparotomy, greater than 2.5 hours of lysis of dense adhesions, cholecystectomy, takedown and closure of cholecystoduodenal fistula, and enterotomy with removal of gallstones from the ileum! I have to believe I can get him paid for something other than the lysis of adhesions or laparotomy! Please see below note and help is greatly appreciated. I will pick up the note once incision made:
Approximately 800 cc of ascites was evacuated from the abdomen resulting from the inflammatory process in the right upper quadrant of the abdomen. The omentum was adhesed to the anterior abdominal wall. This was lysed through a combination of blunt dissection and lysed with Metzenbaum scissors and Bovie. Once the omentum was released from the anterior abdominal wall, the incision was lengthened past the umbilicus to just proximal to the pubic symphysis. Once this was done, adhesions were found in the pelvis. Small bowel was stuck to the anterior abdominal wall, which was gently lysed with Metzenbaum scissors. Once the abdomen was full opened, a Bookwalter retractor was placed to provide adequate exposure in the abdomen. In the pelvis, there were noted to be dense adhesions of small bowel from her prior hysterectomy. The adenolysis continued for approximately 2 1/2 hours where each interloop adhesion and adhesed bowel were carefully lysed taking care not to injure the bowel. Once the bowel was mobilized from the pelvis and was brought into the operative field, the small bowel was freed from its attachement to the under surface of the omentum. The operation continued into the right upper quadrant where there was significant inflammatory reaction in the area of the duodenal bulb where the fistulous communication with the gallbladder was identified as well as several stones which could be palpated. Staying close to the gallbladder and beginning laterally, the ballbladder was bluntly dissected from its attachment to the liver on the left side. A plane between the medial side of the gallbladder was identified and using Metzenbaum scissors, this was carefully lyssed makind sure not to injure the duodenum. Once the plane was cleared, the cystic artery was identified and ligated with 3-0 silk sutures. The gallbladder wall was amputated and passed off the table as specimen. The opening in the fistulas in the small bowel was identified and defined. Allis clamps were placed on the edges of the bowel and the bowel was closed primarily with interrupted 3-0 silk sutures along its length. This area was very inflamed. The repair was then reinforced with omentum which was brought into the right upper quadrant from the transverse colon and it was then tacked in 5 positions with silk sutures completely reinforcing the repair of the duodenum. Once this was completed the abdominal cavity was then irrigated with copious amounts of bacitracin saline solution and then evacuated by suction. The bowel was palpated from the ligament of Treitz to the terminal ileum. There were gallstaones removed from the bowel through and etereotomy. There was very small soilage of ileal contents into the abodominal cavity. This was quickly cleaned up with lap sponges. This was some distance away from the ileocecal valve. The bowel was opened transversely and closed longitudinally with sile sutures and reinforced with a Lembert stitch. Of note, when the fistula was separated from the gallbladder, several large gallstones and small stones were removed, approximately 5 to 7 in total.
Soo, ideas/suggestions on how to bill this one?
Thanks,
Hunter Smith, CPC
