ksrkelly7
Networker
I could really use some help. This patient had 4 surgeries in one day, and 1 two days later. All with surgeons and assistant surgeons from the same group. I have attached brief OP notes, not the whole thing. I am struggling with the modifiers as well. I know there are additional codes but I believe they bundle. This is what I am thinking...
Surg 1 43840.52
Surg 2 49002.78
Surg 3 49002.78
Surg 4 48146.78
Surg 5 48140.58
all assistants 80
SURGERY 1 day 1
Postoperative Diagnosis
GSW abdomen, gastrotomy x2, intra-abdominal hemorrhage
Operation
Damage control laparotomy with exploration of the abdomen, gastrorrhaphy x2, ligation of bleeding gastric vessel, abdominal packing, and temporary abdominal closure
SURGERY 2 day 1
GSW abdomen s/p damage control laparotomy, suspected intra-abdominal bleeding, acidosis, coagulopathy, hypothermia
Postoperative Diagnosis
GSW abdomen s/p damage control laparotomy, intra-abdominal bleeding, acidosis, coagulopathy, hypothermia
Operation
Re-exploration of abdomen with abdominal packing and temporary abdominal closure
SURGERY 3 day 1
PREOPERATIVE DIAGNOSIS:
Gunshot wound to the back, multiple operations.
POSTOPERATIVE DIAGNOSIS:
Avulsion of splenic vein, grade 3 pancreatic injury.
PROCEDURE:
1. Exploratory laparotomy, re-open laparotomy secondary to hypotension and
possibility of hemorrhagic shock.
2. Clipping of the splenic vein.
3. Packing of gunshot wound with a quick clot.
4. Temporary abdominal closure secondary to damage control surgery.
SURGERY 4 day 1
Indication for Surgery
retroperitoneal hemorrhage persistent
Postoperative Diagnosis
same
Operation
reopen laparotomy
distal pancreatectomy
control retroperitoneal hemorrhage
SURGERY 5 day 3
PREOPERATIVE DIAGNOSES:
1. Gunshot wound to the abdomen, zone 1.
2. Intra-abdominal catastrophe, multiple operations for control of
hemorrhage.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to the abdomen, zone 1.
2. Intra-abdominal catastrophe, multiple operations for control of
hemorrhage.
PROCEDURE:
1. Reopen exploratory laparotomy.
2. Exploration of retroperitoneal space, zone #1.
3. Splenectomy.
4. Distal pancreatectomy.
Surg 1 43840.52
Surg 2 49002.78
Surg 3 49002.78
Surg 4 48146.78
Surg 5 48140.58
all assistants 80
SURGERY 1 day 1
Postoperative Diagnosis
GSW abdomen, gastrotomy x2, intra-abdominal hemorrhage
Operation
Damage control laparotomy with exploration of the abdomen, gastrorrhaphy x2, ligation of bleeding gastric vessel, abdominal packing, and temporary abdominal closure
SURGERY 2 day 1
GSW abdomen s/p damage control laparotomy, suspected intra-abdominal bleeding, acidosis, coagulopathy, hypothermia
Postoperative Diagnosis
GSW abdomen s/p damage control laparotomy, intra-abdominal bleeding, acidosis, coagulopathy, hypothermia
Operation
Re-exploration of abdomen with abdominal packing and temporary abdominal closure
SURGERY 3 day 1
PREOPERATIVE DIAGNOSIS:
Gunshot wound to the back, multiple operations.
POSTOPERATIVE DIAGNOSIS:
Avulsion of splenic vein, grade 3 pancreatic injury.
PROCEDURE:
1. Exploratory laparotomy, re-open laparotomy secondary to hypotension and
possibility of hemorrhagic shock.
2. Clipping of the splenic vein.
3. Packing of gunshot wound with a quick clot.
4. Temporary abdominal closure secondary to damage control surgery.
SURGERY 4 day 1
Indication for Surgery
retroperitoneal hemorrhage persistent
Postoperative Diagnosis
same
Operation
reopen laparotomy
distal pancreatectomy
control retroperitoneal hemorrhage
SURGERY 5 day 3
PREOPERATIVE DIAGNOSES:
1. Gunshot wound to the abdomen, zone 1.
2. Intra-abdominal catastrophe, multiple operations for control of
hemorrhage.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to the abdomen, zone 1.
2. Intra-abdominal catastrophe, multiple operations for control of
hemorrhage.
PROCEDURE:
1. Reopen exploratory laparotomy.
2. Exploration of retroperitoneal space, zone #1.
3. Splenectomy.
4. Distal pancreatectomy.