Wiki LAP APPY THEN RETURN TO OR

[hsmith67]

Patient presented for emergency lap appendectomy and surgery was completed with no complications. However, post-op patient started declining, hypotensvie and tachycardic. MRI of abdomen revealed massive hemoperitoneum. Patient was informed and then disclosed that he regrettably had not told the docs of his family history of Factor V Leiden disease - a genetic disease that causes blood clots. Doc returned patient to OR for emergent exploration and evacuation of 800 cc blood clot and 750 cc of liquid blood. During the exploration the surgical site from lap appy done earlier that day was confirmed to be hemostatic. "The retroperitoneum in the right lower quadrant of the abdomen was infiltrated with blood in the soft tissues forming a non-drainable hematoma." A Blake drain was placed and connected to continuous bulb suctioning.

So, can someone give me some advice on how to code this?

Thanks in advance for any help,

Hunter Smith, CPC

 

[thomas7331]

Not sure if you're looking for help on the CPT or the ICD-10, but either way, there's not quite enough info here to be able to code - you really need to see the whole operative report. If the second operation was done by open approach, then for CPT, you're probably looking at 49060-78 if it was just an exploration and evacuation without any other interventions.