Hoping someone can help.
Pt had bile leak s/p Lap chole. Dr billing Lap Diagnostic 49320
Do you agree or is there a better CPT to use? Here is the OP note.
Any help is greatly appreciated!!!
Postoperative Diagnosis: Bile leak
Patient developed significant abdominal pain postoperatively with a CT of the abdomen and pelvis showing possible bile leak. She's taken to the OR for a diagnostic laparoscopy.
After informed consent, patient was brought to the operating room and placed on the gurney in supine position. After adequate general anesthesia was administered, patient's abdomen was prepped and draped in normal sterile fashion. An infraumbilical incision was created. Incision was deepened through the subcu tissue. Linea alba was divided sharply. The peritoneum was penetrated using blunt dissection. A 10 mm trocar was inserted the open technique. With the abdomen insufflated, a quick exploration revealed moderate amount of intra-abdominal bile, consistent with a bile leak. A 5 mm trocar was placed at the right lower quadrant, and another one placed in the left lower quadrant. Suction irrigator was placed into the abdomen. The bile was quickly aspirated. The liver bed was examined showing an active leaking duct of Luschka, halfway up the gallbladder fossa. The leak was isolated, and controlled with hemoclips. The abdomen was then irrigated with 10 L of normal saline until all irrigant were clear. A 15 French Blake drain was placed through the right lower quadrant, and positioned in the gallbladder fossa. Another 15 French Blake drain was placed through the left lower quadrant, and position in the pelvis. The trochars were removed under direct visualization the camera. All port sites were anesthetized with half percent Marcaine. Fascial defects were approximated using 0 Vicryl sutures. Subcutaneous tissue as well as the skin were closed using absorbable suture. Patient tolerated procedure well.
Drains
15 French)Jackson-Pratt drain(s) with closed bulb suction in the abdomen
Implants: * No implants in log *
Specimens: None
Pt had bile leak s/p Lap chole. Dr billing Lap Diagnostic 49320
Do you agree or is there a better CPT to use? Here is the OP note.
Any help is greatly appreciated!!!
Postoperative Diagnosis: Bile leak
Patient developed significant abdominal pain postoperatively with a CT of the abdomen and pelvis showing possible bile leak. She's taken to the OR for a diagnostic laparoscopy.
After informed consent, patient was brought to the operating room and placed on the gurney in supine position. After adequate general anesthesia was administered, patient's abdomen was prepped and draped in normal sterile fashion. An infraumbilical incision was created. Incision was deepened through the subcu tissue. Linea alba was divided sharply. The peritoneum was penetrated using blunt dissection. A 10 mm trocar was inserted the open technique. With the abdomen insufflated, a quick exploration revealed moderate amount of intra-abdominal bile, consistent with a bile leak. A 5 mm trocar was placed at the right lower quadrant, and another one placed in the left lower quadrant. Suction irrigator was placed into the abdomen. The bile was quickly aspirated. The liver bed was examined showing an active leaking duct of Luschka, halfway up the gallbladder fossa. The leak was isolated, and controlled with hemoclips. The abdomen was then irrigated with 10 L of normal saline until all irrigant were clear. A 15 French Blake drain was placed through the right lower quadrant, and positioned in the gallbladder fossa. Another 15 French Blake drain was placed through the left lower quadrant, and position in the pelvis. The trochars were removed under direct visualization the camera. All port sites were anesthetized with half percent Marcaine. Fascial defects were approximated using 0 Vicryl sutures. Subcutaneous tissue as well as the skin were closed using absorbable suture. Patient tolerated procedure well.
Drains
15 French)Jackson-Pratt drain(s) with closed bulb suction in the abdomenImplants: * No implants in log *
Specimens: None