b07mw
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Should I have coded for 49000?
Operative Report
Pre-procedure diagnosis:
Concern for nonviable bowel
Post-procedure diagnosis: same as pre-procedure dx
Procedures performed:
Exploratory laparotomy
Technique/Procedure:
Again, I was asked to see the patient intraoperatively. On entry into the operating room the patient had just delivered via C-section. There was a low transverse Pfannenstiel incision. The uterus was closed. I then began evaluating the small bowel through this incision. I was able to evaluate the majority of the small bowel. I was unable to evaluate the entirety of the Roux limb. I was able to identify the jejunojejunostomy. There was not noted to be any internal hernia. The bowel was evaluated down to the cecum. The bowel was bluish pink. It had good peristalsis. There were good pulses throughout the mesentery. The bowel was all warm. I suspect that bowel had this darker color from blood in the small bowel. There were no signs that the patient had bowel ischemia. All bowel was then placed back into the abdominal cavity. I then turned the case back over to the OBGYN for closure.
Primary Surgeon:
OBGYN
Assistant(s): (OBGYN) Anesthesia: general anesthesia Indications:
35-year-old female who I was asked to see intraoperatively for concerns of nonviable bowel. Patient was taken to the OR for emergent C-section. During the operation the bowel was noted to be somewhat dusky. I was asked to see her intraoperatively to evaluate the small bowel. She does have a known GI bleed which is thought to be from a marginal ulcer at her gastrojejunostomy. She did have a Roux-en-Y gastric bypass approximately 10 years ago in San Antonio.
Operative Report
Pre-procedure diagnosis:
Concern for nonviable bowel
Post-procedure diagnosis: same as pre-procedure dx
Procedures performed:
Exploratory laparotomy
Technique/Procedure:
Again, I was asked to see the patient intraoperatively. On entry into the operating room the patient had just delivered via C-section. There was a low transverse Pfannenstiel incision. The uterus was closed. I then began evaluating the small bowel through this incision. I was able to evaluate the majority of the small bowel. I was unable to evaluate the entirety of the Roux limb. I was able to identify the jejunojejunostomy. There was not noted to be any internal hernia. The bowel was evaluated down to the cecum. The bowel was bluish pink. It had good peristalsis. There were good pulses throughout the mesentery. The bowel was all warm. I suspect that bowel had this darker color from blood in the small bowel. There were no signs that the patient had bowel ischemia. All bowel was then placed back into the abdominal cavity. I then turned the case back over to the OBGYN for closure.
Primary Surgeon:
OBGYN
Assistant(s): (OBGYN) Anesthesia: general anesthesia Indications:
35-year-old female who I was asked to see intraoperatively for concerns of nonviable bowel. Patient was taken to the OR for emergent C-section. During the operation the bowel was noted to be somewhat dusky. I was asked to see her intraoperatively to evaluate the small bowel. She does have a known GI bleed which is thought to be from a marginal ulcer at her gastrojejunostomy. She did have a Roux-en-Y gastric bypass approximately 10 years ago in San Antonio.
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