Wiki Help on coding Op Note

Bondurant, IA
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I am attaching my operative note in hopes that someone can help me. I'm looking at using CPT code 49320. :confused::confused::confused:

PREOPERATIVE DIAGNOSIS: Acute abdomen after dilation and curettage for incomplete miscarriage.

1. Acute abdomen after dilation and curettage for incomplete miscarriage,.
2. Hemoperitoneum with uterine perforation from dilation and curettage.

1. Diagnostic laparoscopy.
2. Evacuation of hemoperitoneum.
3. Suture repair of uterine fundus perforation.


DESCRIPTION OF PROCEDURE: The patient was taken emergently to the operating room, and placed in the dorsal lithotomy position with the left arm tucked. The abdomen and perineum was prepped and draped in the normal sterile fashion. The infraumbilical incision was made and dissected down to the fascia. The fascia was grasped with towel clip and elevated. A Veress needle was inserted into the abdomen, and after a normal saline drop test, it was insufflated to 15 mmHg pressure. Next, the Veress was withdrawn, and a 5 mm non-bladed Ethicon trocar was inserted into the abdomen. A laparoscope was place through this, finding a copious amount of hemoperitoneum, a lot of blood in the pelvis and clot. Bilateral lower quadrant abdominal trocars were place. We triangulated the pelvis. A suction device was used to evacuate all the blood and clot. I exchanged the left lower quadrant 5 mm trocar for an 11 mm trocar so I could use the larger bore suction, and we evacuated all the clot and blood, and prior to irrigation this measured 1000 mL of blood and clot evacuated from the abdomen and pelvis. The patient was then placed in Trendelenburg position. It was obvious that there was a uterine perforation at the fundus. I elevated the uterus, and looked in the cul-de-sac. I placed the patient in Trendelenburg position, and evacuated carefully, the sigmoid colon and rectum, which was fallen into the pelvis. There was no evidence perforation of the rectum or sigmoid colon, as we follow this from the distal aspect, all the way up to the adhesions on the left pelvic sidewall at the white line of Toldt. There is no evidence of perforation of the small intestine either. No posterior perforation of the uterus, and no anterior perforation of the uterus. Only on the uterine fundus at the apex. The bladder was decompressed with a Foley catheter. There was no evidence of perforation in this area. The iliac vessels bilaterally were intact, without any evidence of rupture of even the peritoneal covering. The pelvis was suctioned irrigated until the effluent was clear. We suctioned the abdomen, raised the omentum, inspected the small intestine by running this from the terminal ileum more proximally. There is no evidence of any perforation there. The appendix looked normal, and was left in place. We then turned our attention to repairing the uterine perforation at the fundus.

A Single stitch of 0 Vicryl suture was used to laparoscopically embrocate with a Lembert type fashion suture with a healthy bite of tissue on each side, tying this taut, and closing the perforation. There was no further evidence of bleeding. In fact, the uterine perforation did not have much bleeding at the time of surgery. I continued to evacuate the remainder of the abdomen, irrigated it copiously. I placed the patient back in the flat position, irrigated the upper quadrants and suctioned this dry, placed the omentum back in its normal anatomic position, and under direct visualization, closed the 11 mm trocar site with 0 Vicryl suture in Endo closed technique. Marcaine 0.5% was infiltrated in all the wounds for postoperative pain relief. The trocars were withdrawn, the abdomen allowed to deflate. The wounds Were closed with 4-0 Monocryl suture. Mastisol and Steri-strips were applied. She was taken to the recovery room in satisfactory condition, with all needles, sponges, and instrument counts being correct