maine4me
Guru
Would someone please review this operative report? The doctored billed this as 44950 and 49203. I do not think the 49203 is appropriate since there is no mention of what the "intra-abdominal collections" was. The abscess was previously drained according to the note. Also no mention of repair of the hernia. Any help would be appreciated.
PREOPERATIVE DIAGNOSIS: S/P Ruptured acute appendicitis with abscess; S/P IR drainage.
POSTOPERATIVE DIAGNOSIS:
1.S/P Ruptured acute appendicitis with abscess; S/P IR drainage.
2.Intra-abdominal collection.
3.Ventral incisional hernia.
OPERATION:
1.Interval appendectomy.
2.Excision of intra-abdominal collection (en bloc with appendix).
3.Repair of ventral incisional hernia.
INDICATIONS FOR PROCEDURE: Patient is a 51-year-old white female who presented to the hospital in 11/2011 with right lower quadrant abdominal pain for two weeks and a ruptured appendix. The patient underwent Interventional Radiology drainage of the abscess.
OPERATIVE FINDINGS: The patient had chronically ruptured appendicitis with an intra-abdominal collection adjacent and attached to the appendiceal tip. The patient also had a ventral incisional hernia containing part of the sigmoid colon.
PROCEDURE: Patient was brought to the Operating Room and was placed on the operating table in the supine position. A Time Out procedure was accomplished. After being correctly identified as to identity, correct operative site, and operative procedure planned, general orotracheal anesthesia was administered by Grand View Anesthesia Associates. Foley catheter was inserted. The abdomen was prepped and draped in usual sterile fashion. A right sided mid-abdominal incision was made in a paramedian fashion and was carried down through subcutaneous fat and through the right anterior rectus muscle fascia. Bleeding was controlled using electrocautery. The right rectus muscle was then retracted laterally, and the posterior rectus fascia and peritoneum were then incised.
Upon entering the peritoneum, the above findings were encountered. The sigmoid colon was dissected from the ventral incisional hernia without injury to the colon. The appendix was identified and the mesoappendix was divided using #0 Vicryl ligatures and the Harmonic Super Jaw Device. Once the mesoappendix was completely divided, the base of the appendix was then transected using a GIA stapler. The collection overlying the right iliac vessels was then dissected free and removed en bloc (intact) with the appendix. The cecum was returned to the peritoneal cavity. All free fluid was aspirated from the pelvis.
At this point, the wound and peritoneal cavity were inspected for bleeding and there was none. The bowel was placed in its normal anatomical position. The posterior rectus fascia and peritoneum were closed using a running #1 Prolene suture. Anterior rectus fascia was closed using a running #1 Prolene suture with the knots buried. This muscular closure included closure of the ventral incisional hernia. Subcutaneous fat was closed with #2-0 Vicryl suture. Skin was closed using staples. Dry, sterile dressing was applied and the patient having tolerated the procedure well was awakened and taken to the Post Anesthesia Care Unit in good condition. Sponge, needle counts correct x2; instrument count correct x1. Estimated blood loss - minimal.
PREOPERATIVE DIAGNOSIS: S/P Ruptured acute appendicitis with abscess; S/P IR drainage.
POSTOPERATIVE DIAGNOSIS:
1.S/P Ruptured acute appendicitis with abscess; S/P IR drainage.
2.Intra-abdominal collection.
3.Ventral incisional hernia.
OPERATION:
1.Interval appendectomy.
2.Excision of intra-abdominal collection (en bloc with appendix).
3.Repair of ventral incisional hernia.
INDICATIONS FOR PROCEDURE: Patient is a 51-year-old white female who presented to the hospital in 11/2011 with right lower quadrant abdominal pain for two weeks and a ruptured appendix. The patient underwent Interventional Radiology drainage of the abscess.
OPERATIVE FINDINGS: The patient had chronically ruptured appendicitis with an intra-abdominal collection adjacent and attached to the appendiceal tip. The patient also had a ventral incisional hernia containing part of the sigmoid colon.
PROCEDURE: Patient was brought to the Operating Room and was placed on the operating table in the supine position. A Time Out procedure was accomplished. After being correctly identified as to identity, correct operative site, and operative procedure planned, general orotracheal anesthesia was administered by Grand View Anesthesia Associates. Foley catheter was inserted. The abdomen was prepped and draped in usual sterile fashion. A right sided mid-abdominal incision was made in a paramedian fashion and was carried down through subcutaneous fat and through the right anterior rectus muscle fascia. Bleeding was controlled using electrocautery. The right rectus muscle was then retracted laterally, and the posterior rectus fascia and peritoneum were then incised.
Upon entering the peritoneum, the above findings were encountered. The sigmoid colon was dissected from the ventral incisional hernia without injury to the colon. The appendix was identified and the mesoappendix was divided using #0 Vicryl ligatures and the Harmonic Super Jaw Device. Once the mesoappendix was completely divided, the base of the appendix was then transected using a GIA stapler. The collection overlying the right iliac vessels was then dissected free and removed en bloc (intact) with the appendix. The cecum was returned to the peritoneal cavity. All free fluid was aspirated from the pelvis.
At this point, the wound and peritoneal cavity were inspected for bleeding and there was none. The bowel was placed in its normal anatomical position. The posterior rectus fascia and peritoneum were closed using a running #1 Prolene suture. Anterior rectus fascia was closed using a running #1 Prolene suture with the knots buried. This muscular closure included closure of the ventral incisional hernia. Subcutaneous fat was closed with #2-0 Vicryl suture. Skin was closed using staples. Dry, sterile dressing was applied and the patient having tolerated the procedure well was awakened and taken to the Post Anesthesia Care Unit in good condition. Sponge, needle counts correct x2; instrument count correct x1. Estimated blood loss - minimal.