Coastal Coder
Networker
Below is a procedure note that I am in need of help with, I have searched the CPT book and I am at a lose for a code to describe this.
Any help would be greatly appreciated.
DESCRIPTION OF PROCEDURE:
He was brought into the operating room suite. He was placed in the supine position where he was placed
under general anesthesia without any complications. He was then rolled into the jack-knife prone position. His buttocks were taped to the side, and he was prepped and draped in the usual sterile fashion. It was clearly visible but there was one arterial bleeder that was located in the wound bed. It was actually on the buttocks just outside of the anus and not actually inside of the anus. I used a 3-0 catgut and placed a figure-of-eight suture deep into the tissues around this bleeder, and then used electrocautery as well. There were some other areas that were oozing slightly, and these were controlled with electrocautery, but this initial arterial bleeder clearly was the source of his excessive blood loss. I inspected the entire fistula tract. I inserted a retractor into the
anus to make sure that there was nothing bleeding from higher up, there clearly was not. The rest of the wound
bed appeared to be dry. I irrigated with normal saline. I infiltrated the entire area with Marcaine combined with epinephrine. I then packed the wound with Surgicel and then 4x4s and fluff gauze and ABO. The patient was awoken from anesthesia and transferred to the recovery room in stable condition. Needle, sponge, and instrument counts were all correct at the end of the case. The patient tolerated the procedure well. He will
likely be discharged from the recovery room today. Needle, sponge, and instrument counts were all correct at the end of the case.
Any help would be greatly appreciated.
DESCRIPTION OF PROCEDURE:He was brought into the operating room suite. He was placed in the supine position where he was placed
under general anesthesia without any complications. He was then rolled into the jack-knife prone position. His buttocks were taped to the side, and he was prepped and draped in the usual sterile fashion. It was clearly visible but there was one arterial bleeder that was located in the wound bed. It was actually on the buttocks just outside of the anus and not actually inside of the anus. I used a 3-0 catgut and placed a figure-of-eight suture deep into the tissues around this bleeder, and then used electrocautery as well. There were some other areas that were oozing slightly, and these were controlled with electrocautery, but this initial arterial bleeder clearly was the source of his excessive blood loss. I inspected the entire fistula tract. I inserted a retractor into the
anus to make sure that there was nothing bleeding from higher up, there clearly was not. The rest of the wound
bed appeared to be dry. I irrigated with normal saline. I infiltrated the entire area with Marcaine combined with epinephrine. I then packed the wound with Surgicel and then 4x4s and fluff gauze and ABO. The patient was awoken from anesthesia and transferred to the recovery room in stable condition. Needle, sponge, and instrument counts were all correct at the end of the case. The patient tolerated the procedure well. He will
likely be discharged from the recovery room today. Needle, sponge, and instrument counts were all correct at the end of the case.
