Diag Lap or Appppendectomy ? Pls Help

bill2doc

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Would this be Diag Lap or Appendectomy? Please help with CPT codes.. Thank you !

PREOPERATIVE DIAGNOSIS: Acute abdomen.

POSTOPERATIVE DIAGNOSIS: Typhlitis.

PROCEDURES:
1. Diagnostic laparoscopy.
2. Appendectomy.

SPECIMENS: Included appendix. Findings include normal appendix with an inflamed cecum.

The decision was then made to bring her to the operating room for laparoscopic exploration and appendectomy.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. An infraumbilical curvilinear incision was then made and carried down through the subcutaneous tissues. The umbilical stalk was then grasped and elevated and the fascia exposed. A midline fascial incision Hasson trocar was then introduced and pneumoperitoneum was established. Evaluation of the abdomen on initial entry noted no evidence of injury to the bowel with the trocar placement and an inflammatory mass in the right lower quadrant, 5-mm ports were then placed through separate stab incisions in the suprapubic and left lower quadrant positions. The inflammatory mass was then examined. Of note, a normal appendix was found but the cecum appeared to be dilated and injected with some inflammatory changes throughout the cecum. The small bowel at the terminal ileum appeared to be mildly injected and somewhat dilated but the major inflammatory changes appeared to be at the cecum itself. The cecum was boggy and indurated but there is no evidence of mass effects, rupture or abscess. The small bowel was examined and there is no evidence of Meckel's diverticulitis. The pelvis was examined and the uterus appeared normal with normal-appearing ovaries and adnexa. There was some serous fluid in the cul-de-sac which was evacuated. The appendix was then dissected free of the surrounding tissue. The mesoappendix was divided with the LigaSure device and a linear stapler was then used to divide the appendix across this space. The stump appeared to be healthy with no evidence of perforation or bleeding. The appendix was then extracted And the abdomen was again irrigated and the abdomen was again examined and there is no evidence of further areas of inflammation or injury. The ports were then removed under direct vision. The previously placed fascial sutures were then tied and the skin incisions were closed with a running subcuticular 4-0 Vicryl. Steri-Strips and dressings were then applied.
 

mitchellde

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sorry my CPT book is not available but you would code the appy only you do not code the diagnostic xlap once a definitive procedure is performed.
 

purplescarf23

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I would consider the diag laparoscopy bundled into the lap appy. I would bill 44970. Granted it started out as diag lap but the provider actually did a procedure so we have always coded the actual procedure. Hope that helps.

Kelsey, CPC
 
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