Can someone please help me - I am fairly new to trauma coding and I have a procedure that I am not sure how to code. The op note is as follows:
Postoperative Diagnosis: Ascites
A small midline laparotomy incision was made, as the patient had been on Plavix and other blood thinners. The laceration itself had to be controlled with unipolar electrocautery and spot coagulation. At this time, the peritoneum was opened under direct visualization and obtained serous straw-colored fluid, small mini lap was done. We looked around gently, but two pool suckers were placed in, approximately 2.5 liters of straw-colored fluid was removed, and the patient had a closure of the fascia with #2 figure-of-eight Vicryl sutures and staples for skin.
I was considering 49000-52 or 49020.
I could really used someone's expertise since I am so new to this.
Thank you!
Postoperative Diagnosis: Ascites
A small midline laparotomy incision was made, as the patient had been on Plavix and other blood thinners. The laceration itself had to be controlled with unipolar electrocautery and spot coagulation. At this time, the peritoneum was opened under direct visualization and obtained serous straw-colored fluid, small mini lap was done. We looked around gently, but two pool suckers were placed in, approximately 2.5 liters of straw-colored fluid was removed, and the patient had a closure of the fascia with #2 figure-of-eight Vicryl sutures and staples for skin.
I was considering 49000-52 or 49020.
I could really used someone's expertise since I am so new to this.
Thank you!
- I do appreciate your help, but it is definitely an open procedure and there was no imaging guidance.