I'm needing help with CPT codes please!
The patient below underwent a lap chole and returned to the ER a couple days later for abdominal wall hematoma. The dr describes the procedure as an evacuation of abdominal wall hematoma.
Op Note:
A subcostal incision was made. Using the cautery, we incised the anterior rectus sheath and almost immediately was a large expression of blood clot. We incised the remainder or the rectus muscle with cautery. Clot and old blood was evacuated throughout the entire length of the rectus sheath. Oozing vessels and oozing from the rectus was controlled with cautery. I incised the posterior sheath and the peritoneum to inspect intra-abdominally and there was no bleeding from here.
The posterior sheath and peritoneum were closed with a running 0Vicryl continuous suture. Hemostasis of the rectus sheath was felt to be excellent. A large Blake drain was placed within the sheath and brought out through a separate lateral insicion, securing it to the skin with a 2-0 silk. The anterior sheath was closed with a running 0 looped PDS continuous suture. The skin was closed with a stapler.
any help is much appreciated!
The patient below underwent a lap chole and returned to the ER a couple days later for abdominal wall hematoma. The dr describes the procedure as an evacuation of abdominal wall hematoma.
Op Note:
A subcostal incision was made. Using the cautery, we incised the anterior rectus sheath and almost immediately was a large expression of blood clot. We incised the remainder or the rectus muscle with cautery. Clot and old blood was evacuated throughout the entire length of the rectus sheath. Oozing vessels and oozing from the rectus was controlled with cautery. I incised the posterior sheath and the peritoneum to inspect intra-abdominally and there was no bleeding from here.
The posterior sheath and peritoneum were closed with a running 0Vicryl continuous suture. Hemostasis of the rectus sheath was felt to be excellent. A large Blake drain was placed within the sheath and brought out through a separate lateral insicion, securing it to the skin with a 2-0 silk. The anterior sheath was closed with a running 0 looped PDS continuous suture. The skin was closed with a stapler.
any help is much appreciated!