Wiki Attempted closed reduction of incarcerated hernia.

[Bridgetln]

I'm seeking coding advice. Any help would be greatly appreciated.

The patient was seen in the office for a incarcerated right inguinal hernia. The physician then attempted to manually manipulate the hernia. Below I have included the description of procedure.

"With patient under general anesthetic, attempts were made for approximately seven minutes to try to reduce his right inguinal hernia. These attempts were unsuccessful. The patient does has coagulopathy secondary to aspirin. I will plan to keep him off of his aspirin and reduce his hernia operatively when appropriate regarding cessation of aspirin. Also, discussed with him the warning signs to look out for strangulation."

Thank you for your help!

 

[ardithch]

Attempted closed reduction of incarcerated hernia

This seems a little off to me. If the patient has an incarcerated hernia that cannot be reduced, he/she should be sent to the emergency room.

Your note states that the patient was under general anesthesia in the office? This may need clarification.

If it's just trying to reduce the hernia in the office and that is unsuccessful, you'd just bill an E/M. But this note requires greater clarification.

Hope this helps,

Ardith, CGSC

 

[Bridgetln]

My apologies this was done as an outpatient procedure on the OR.