lbermudez@mms-ms.com
Contributor
Not sure if this one is an easy one or not but ...
I need second opinion coding a procedure. It's 3 surgeons, they all made separate notes. After overthinking
this I ended up with :
Dr. A bills for - 44140 , 44139, 58150-80, and maybe 50715-80?
Dr. B bills for - 52332-80, 76000-26
Dr. C bills for - 58150 and maybe 50715-59
...Betadine was performed both to the perineum as well as the abdominal cavity additional barrier protection in the form of an Ioban dressing was also utilized. With this done the patient had bilateral ureteral stents placed during the procedure the patient was noted to have some restriction and difficulty placing the right-sided stent secondary to the pelvic inflammatory process however this was placed successfully under fluoroscopic guidance separate operative report will follow. With this done Dr. C and I open the lower midline abdomen from the umbilicus to the pubic symphysis. Upon entering this we were able to then identify a rockhard phlegmon within the pelvis involving the uterus and sigmoid colon. The sigmoid colon is markedly thickened for a distance of approximately 10 to 15 cm. With this done we initially tried to separate the uterus from the sigmoid colon but this was untenable secondary to the inflammatory process we transected the colon at the junction of the mid descending and sigmoid colon with a GIA stapling device we carried our dissection into the true pelvis and initiated mesorectal excision while we are not concerned about the possibility of malignancy we did this also to facilitate identification of the ureters thankfully the ureteral stents became palpable as we fractured the tumor especially from the left pelvic sidewall. In doing so we also were able to then continue our fracturing of the uterus from the bladder. At this point Dr. C performed an abdominal hysterectomy with bilateral salpingo-oophorectomy. Details of this operation will follow under separate cover. The patient also underwent a ureterolysis especially of the left ureter as it is rather central within the pelvic phlegmon the right ureter was not disturbed from its native bed. With the hysterectomy performed we then had a clear delineation of the completed closure of the vaginal cuff and the remaining colon there is not a significant amount of residual diverticular disease in the lower descending colon but there is some degree of stricture with this noted I made the decision to mobilize the entirety of the left colon and the splenic flexure to facilitate a tension-free anastomosis. We were able to do this but Mesentery and tract utilizing immune O fluorescence we could identify clearly are intended point of transection was clear the Museux colon and mesorectum had been transected and the distal colon transected with a contour stapling device approximately 3 to 4 cm above the pelvic reflection. With this done we also could then bring the colon into the pelvis I did note that secondary to some of the tethering of the mesentery it was easier to bring the side of the left/descending colon and rather than a true end-to-end anastomosis we therefore transected the colon secondary to the degree of longstanding obstruction the descending colon is markedly dilated and easily excepted the anvil of a 33 mm stapling device. The end of the colon was transected and the anvil of our stapling device brought out through the antimesenteric surface of the colon. The 33 mm ILS stapler was placed transanally and brought up through our more proximal point of transection with this done we and joined our staple line and colon created a circular 33 mm anastomosis 2 intact donuts of tissue were retrieved. The anterior surface of our anastomosis was buffered with a with interrupted 3-0 silk sutures in an interrupted seromuscular Lembert fashion. With this done we performed rigid proctoscopy and our anastomosis is widely patent. Intact some of the mesentery of the colon to the transected posterior peritoneum to prevent adhesions or ductal bowel from entering and causing any obstruction behind our mobilized descending colon. With this done we irrigated copiously we ensured hemostasis and all of our operative beds. A retrocecal appendix was identified this was elevated the mesoappendix was transected with the harmonic scalpel and amputated from the base of the colon with a single fire of the GIA stapling device. With this done we initiated closure a 19 French Blake drain was placed into the pelvis we did also did tacked the omentum between the anastomosis and the reconstructed vaginal cuff. We initiated closure of the peritoneum with a running suture of #1 Vicryl. The fascia of the abdominal wall was approximated with looped #1 PDS suture with interrupted internal retention sutures of #2 Vicryl.
I need second opinion coding a procedure. It's 3 surgeons, they all made separate notes. After overthinking
this I ended up with :Dr. A bills for - 44140 , 44139, 58150-80, and maybe 50715-80?
Dr. B bills for - 52332-80, 76000-26
Dr. C bills for - 58150 and maybe 50715-59
...Betadine was performed both to the perineum as well as the abdominal cavity additional barrier protection in the form of an Ioban dressing was also utilized. With this done the patient had bilateral ureteral stents placed during the procedure the patient was noted to have some restriction and difficulty placing the right-sided stent secondary to the pelvic inflammatory process however this was placed successfully under fluoroscopic guidance separate operative report will follow. With this done Dr. C and I open the lower midline abdomen from the umbilicus to the pubic symphysis. Upon entering this we were able to then identify a rockhard phlegmon within the pelvis involving the uterus and sigmoid colon. The sigmoid colon is markedly thickened for a distance of approximately 10 to 15 cm. With this done we initially tried to separate the uterus from the sigmoid colon but this was untenable secondary to the inflammatory process we transected the colon at the junction of the mid descending and sigmoid colon with a GIA stapling device we carried our dissection into the true pelvis and initiated mesorectal excision while we are not concerned about the possibility of malignancy we did this also to facilitate identification of the ureters thankfully the ureteral stents became palpable as we fractured the tumor especially from the left pelvic sidewall. In doing so we also were able to then continue our fracturing of the uterus from the bladder. At this point Dr. C performed an abdominal hysterectomy with bilateral salpingo-oophorectomy. Details of this operation will follow under separate cover. The patient also underwent a ureterolysis especially of the left ureter as it is rather central within the pelvic phlegmon the right ureter was not disturbed from its native bed. With the hysterectomy performed we then had a clear delineation of the completed closure of the vaginal cuff and the remaining colon there is not a significant amount of residual diverticular disease in the lower descending colon but there is some degree of stricture with this noted I made the decision to mobilize the entirety of the left colon and the splenic flexure to facilitate a tension-free anastomosis. We were able to do this but Mesentery and tract utilizing immune O fluorescence we could identify clearly are intended point of transection was clear the Museux colon and mesorectum had been transected and the distal colon transected with a contour stapling device approximately 3 to 4 cm above the pelvic reflection. With this done we also could then bring the colon into the pelvis I did note that secondary to some of the tethering of the mesentery it was easier to bring the side of the left/descending colon and rather than a true end-to-end anastomosis we therefore transected the colon secondary to the degree of longstanding obstruction the descending colon is markedly dilated and easily excepted the anvil of a 33 mm stapling device. The end of the colon was transected and the anvil of our stapling device brought out through the antimesenteric surface of the colon. The 33 mm ILS stapler was placed transanally and brought up through our more proximal point of transection with this done we and joined our staple line and colon created a circular 33 mm anastomosis 2 intact donuts of tissue were retrieved. The anterior surface of our anastomosis was buffered with a with interrupted 3-0 silk sutures in an interrupted seromuscular Lembert fashion. With this done we performed rigid proctoscopy and our anastomosis is widely patent. Intact some of the mesentery of the colon to the transected posterior peritoneum to prevent adhesions or ductal bowel from entering and causing any obstruction behind our mobilized descending colon. With this done we irrigated copiously we ensured hemostasis and all of our operative beds. A retrocecal appendix was identified this was elevated the mesoappendix was transected with the harmonic scalpel and amputated from the base of the colon with a single fire of the GIA stapling device. With this done we initiated closure a 19 French Blake drain was placed into the pelvis we did also did tacked the omentum between the anastomosis and the reconstructed vaginal cuff. We initiated closure of the peritoneum with a running suture of #1 Vicryl. The fascia of the abdominal wall was approximated with looped #1 PDS suture with interrupted internal retention sutures of #2 Vicryl.