missyah20
Guru
I have a case where the patient was in an MVC, was pregnant, brought in the ER where an Emergent C-section was performed by an OB. Patient had no pulse. After the C-Section took place in the ER the patient was taken to the OR where the provider I am billing for performed an Exploratory Lap with closure of hysterotomy.
I am wondering what if anything I can bill for here. Thanks! Below is the Op Report:
Procedure Details:
When I came into the OR she was packed and had CPR going and was intubated with an LMA. Dr. Wilson and I scrubbed in and I unpacked her and noted no significant new bleeding apparent at that point. They were doing CPR and I was able to retract the small bowel and palpate the aorta. I was having trouble feeling and actual pulse even with CPT. When they stopped to take a break initially I did not feel anything and they resumed CPR. After another round and rechecking I could feel a thready pulse within the aorta and the iliac on the left. She was intubated and we continued to work while we did have a rhythm at that point and we did have a blood pressure. We are able to suction some of the blood and again noted no ongoing bleeding. Her incision was a low Pfannenstiel and I was able to reach up to the liver and see the edge of it but I was able to palpate it and no obvious laceration was noted. A minimal amount of blood was around the liver. I turned my attention left upper quadrant her stomach was quite distended and OG was placed. Could palpate the spleen and I thought I may be felt something there, but there was no obvious ongoing bleeding and it was hard to see that area so I ended up extending her incision cephalad for a Mercedes type incision. That did facilitate exploration. I was able to visualize the spleen and there seemed to be no obvious injury. No obvious succus was noted and what could be seen of small bowel and colon all seemed to be viable. There is maybe some minimal bruising of the small bowel mesentery. The stomach itself seemed to be uninjured and decompressed nicely. I turned our attention to the hysterotomy. Please see Dr. Wilson's note for that detail but in essentially we were able to close that after retreiving some of the placenta with a running Vicryl stitch. There was not really much active bleeding coming form that when we started doing that. We were able to close that and we checked the bladder. Again no ongoing bleeding was noted at that point. We elected to close the fascia with O looped PDS sutures and then closed with staples. I did explore her scalp injry which was anterior into the right. It felt as though skull was intact and no obvious defect within the skull to indicate an open skull fracture. I quickly stapled that closed. She was left in the OR with anesthesia working on placing an art line and helicopter in route for transfer.
I am wondering what if anything I can bill for here. Thanks! Below is the Op Report:
Procedure Details:
When I came into the OR she was packed and had CPR going and was intubated with an LMA. Dr. Wilson and I scrubbed in and I unpacked her and noted no significant new bleeding apparent at that point. They were doing CPR and I was able to retract the small bowel and palpate the aorta. I was having trouble feeling and actual pulse even with CPT. When they stopped to take a break initially I did not feel anything and they resumed CPR. After another round and rechecking I could feel a thready pulse within the aorta and the iliac on the left. She was intubated and we continued to work while we did have a rhythm at that point and we did have a blood pressure. We are able to suction some of the blood and again noted no ongoing bleeding. Her incision was a low Pfannenstiel and I was able to reach up to the liver and see the edge of it but I was able to palpate it and no obvious laceration was noted. A minimal amount of blood was around the liver. I turned my attention left upper quadrant her stomach was quite distended and OG was placed. Could palpate the spleen and I thought I may be felt something there, but there was no obvious ongoing bleeding and it was hard to see that area so I ended up extending her incision cephalad for a Mercedes type incision. That did facilitate exploration. I was able to visualize the spleen and there seemed to be no obvious injury. No obvious succus was noted and what could be seen of small bowel and colon all seemed to be viable. There is maybe some minimal bruising of the small bowel mesentery. The stomach itself seemed to be uninjured and decompressed nicely. I turned our attention to the hysterotomy. Please see Dr. Wilson's note for that detail but in essentially we were able to close that after retreiving some of the placenta with a running Vicryl stitch. There was not really much active bleeding coming form that when we started doing that. We were able to close that and we checked the bladder. Again no ongoing bleeding was noted at that point. We elected to close the fascia with O looped PDS sutures and then closed with staples. I did explore her scalp injry which was anterior into the right. It felt as though skull was intact and no obvious defect within the skull to indicate an open skull fracture. I quickly stapled that closed. She was left in the OR with anesthesia working on placing an art line and helicopter in route for transfer.