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Help with CPT coding of OP surgery


Lima, Ohio
Best answers

Can someone please provide some guidance regarding CPT coding of the following OP surgery??
Exploration of left groin. Lysis of adhesions. Removal of suture.

SUMMARY: On 09-26-11, the patient was properly identified. Timeout was taken. He was marked appropriately, prepped with Betadine solution and draped in the usual fashion. Regional anesthetic of 0.5% Marcaine with epinephrine was then utilized. A transverse incision was made in the left lower quadrant, actually incorporating the previous incision. This was made through the skin and subcutaneous tissue using sharp and blunt dissection as well as electrocautery. I carried my dissectd down to the external oblique aponeurosis. I divided the fatty tissue off the external oblique aponeurosis. I divided this tissue down toward the previously marked area on the patient's suprapubic area, where he was complaining of the pain. He did have some adhesions down in this particular area. I then went ahead and opened up the external oblique aponeurosis, and I was now able to divide the adhesions. I divided the external oblique aponeurosis off the cord. I took this down toward the patient's area of pain. I was able to reflect the cord medially. I explored this particular area and did not see any evidence of a hernia. What he had was a couple of old Ethibond sutures, one was right down at the pubic tubercle, which seemed to correlate to where the patient's pain was utilizing sharp and blunt dissection. I was able to remove the suture and subsequently sent it to pathology for evaluation. I then examined the area again. Surrounding tissue was all nice and soft. I could not appreciate an obvious hernia. Then closed the external oblique aponeurosis in a running fashion. The skin and subcutaneous tissue was closed in routine fashion with 3-0 chromic and 3-0 PDS. Dressing was applied.

The patient was then taken off the table, placed on the cart, and taken to the recovery room in satisfactory condition.

GROSS PATHOLOGY: The patient is a 66-year-old male, who had bilateral inguinal hernias. It was repaired with mesh plug. He presented to the office several months ago with increasing pain. This was actually in both testicles and down in the groin. Thought possibly a prostatitis. We treated him with antibiotics. He actually seemed to do somewhat better. His symptoms seemed to improve, but it did seem to localize toward the right inguinal area. He had had an ultrasound. There was some confusion. Apparently, they thought there was some peristalsis in the particular area, suggestive of possible hernia. This was negative. He underwent a CT scan, which was essentially negative. With the persistence of pain and lack of definitive etiology, basically we explored this area. The only thing I could find was some adhesions, which were nonspecific, and a stitch granuloma.

Any help would be appreciated!