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I came up with 35702 & 39560, but the Surgeon does not think 35702 is correct. I've looked & can't come up with a better code. See OP note below. Thank you!

OP
DATE OF PROCEDURE: 03/16/2021

PREOPERATIVE DIAGNOSIS: Superior mesenteric artery syndrome, median arcuate ligament syndrome.

POSTOPERATIVE DIAGNOSIS: Superior mesenteric artery syndrome, median arcuate ligament syndrome.

PROCEDURE: Robotically-assisted release of the median arcuate ligament.

PROCEDURE IN DETAIL: The patient was taken to the operating room, laid supine on the operating room table where anesthesia was induced and she was intubated. She was prepped and draped in the standard fashion. A 0.25% Marcaine was used as an umbilical block and a vertical incision was made through the umbilicus into the abdominal cavity, which was entered under direct vision and an 8 mm robotic trocar was placed. The abdomen was insufflated and the three other 8 mm robotic trocars were then placed in succession along an umbilical line axis. One was placed on the right side under direct vision and after infiltration of 0.25% Marcaine, approximately 8 cm away from the umbilicus. After which 2 more were placed, one 5 to 6 cm away from the umbilicus on the left and one 7 cm away from the that also on the left. With all trocars in place, we used instruments to the lift the liver and the Iron Intern was inserted through the epigastrium under direct vision through a small stab wound. This was used to retract the liver anteriorly and cephalad. Once this was in place, the patient was placed in reverse Trendelenburg position and the robot was docked. Once the docking procedure had been completed, I passed a rolled and tied 4 x 4 which passed through the rightmost trocar into the abdominal cavity after which the robot was docked. The rolled 4 x 4 was placed up in the upper quadrants. A retractor was placed in the left most trocar site. A Maryland was used in the third robotic arm, the camera was used and the second robotic arm and a ProGrasp was used in the first robotic arm. With everything in position, we made our way through the pars flaccida with blunt dissection. The right gastric artery was identified and retracted inferolaterally towards the left. This was used as a guide to the celiac artery and the aorta. The aorta was dissected free by blunt dissection down to the nerve fibers, which overlay the junction with the celiac axis. I dissected the vessels down to the adventitia circumferentially around the celiac axis up to the common and to the right gastric circumferentially. A complete release of the artery was guaranteed in this fashion. The median arcuate ligament had been found early in the dissection following the artery down to the aorta and this was lysed with the vessel sealer obtaining immediate release of the previously found tension. With the nerve fibers freed for approximately 200 some degrees around the aorta and circumferentially around the celiac axis with hemostasis noted to be perfectly satisfactory. We removed the gauze cigar, which had been used to dab the area. The instruments were all removed. The robot was undocked. A camera was placed back through the umbilicus into the abdominal cavity, so as to watch the Iron Intern be removed carefully and successfully of the liver had suffered no damage from its presence. A small yellowish nodule was noted on the left lobe of the liver peripherally and inferior. This was approximately 1 cm in greatest diameter and looked like fatty tissue. The trocars were then removed while using passing needle to close the muscle for the operating trocars. The umbilical trocar site was closed with 0 PDS, once the abdomen had been completely desufflated. The skin was closed with 6-0 Monocryl and Dermabond except on the belly button where the gauze dressing was applied. The patient tolerated the procedure well and was taken to the recovery room in excellent condition.
 
I came up with 35702 & 39560, but the Surgeon does not think 35702 is correct. I've looked & can't come up with a better code. See OP note below. Thank you!

OP
DATE OF PROCEDURE: 03/16/2021

PREOPERATIVE DIAGNOSIS: Superior mesenteric artery syndrome, median arcuate ligament syndrome.

POSTOPERATIVE DIAGNOSIS: Superior mesenteric artery syndrome, median arcuate ligament syndrome.

PROCEDURE: Robotically-assisted release of the median arcuate ligament.

PROCEDURE IN DETAIL: The patient was taken to the operating room, laid supine on the operating room table where anesthesia was induced and she was intubated. She was prepped and draped in the standard fashion. A 0.25% Marcaine was used as an umbilical block and a vertical incision was made through the umbilicus into the abdominal cavity, which was entered under direct vision and an 8 mm robotic trocar was placed. The abdomen was insufflated and the three other 8 mm robotic trocars were then placed in succession along an umbilical line axis. One was placed on the right side under direct vision and after infiltration of 0.25% Marcaine, approximately 8 cm away from the umbilicus. After which 2 more were placed, one 5 to 6 cm away from the umbilicus on the left and one 7 cm away from the that also on the left. With all trocars in place, we used instruments to the lift the liver and the Iron Intern was inserted through the epigastrium under direct vision through a small stab wound. This was used to retract the liver anteriorly and cephalad. Once this was in place, the patient was placed in reverse Trendelenburg position and the robot was docked. Once the docking procedure had been completed, I passed a rolled and tied 4 x 4 which passed through the rightmost trocar into the abdominal cavity after which the robot was docked. The rolled 4 x 4 was placed up in the upper quadrants. A retractor was placed in the left most trocar site. A Maryland was used in the third robotic arm, the camera was used and the second robotic arm and a ProGrasp was used in the first robotic arm. With everything in position, we made our way through the pars flaccida with blunt dissection. The right gastric artery was identified and retracted inferolaterally towards the left. This was used as a guide to the celiac artery and the aorta. The aorta was dissected free by blunt dissection down to the nerve fibers, which overlay the junction with the celiac axis. I dissected the vessels down to the adventitia circumferentially around the celiac axis up to the common and to the right gastric circumferentially. A complete release of the artery was guaranteed in this fashion. The median arcuate ligament had been found early in the dissection following the artery down to the aorta and this was lysed with the vessel sealer obtaining immediate release of the previously found tension. With the nerve fibers freed for approximately 200 some degrees around the aorta and circumferentially around the celiac axis with hemostasis noted to be perfectly satisfactory. We removed the gauze cigar, which had been used to dab the area. The instruments were all removed. The robot was undocked. A camera was placed back through the umbilicus into the abdominal cavity, so as to watch the Iron Intern be removed carefully and successfully of the liver had suffered no damage from its presence. A small yellowish nodule was noted on the left lobe of the liver peripherally and inferior. This was approximately 1 cm in greatest diameter and looked like fatty tissue. The trocars were then removed while using passing needle to close the muscle for the operating trocars. The umbilical trocar site was closed with 0 PDS, once the abdomen had been completely desufflated. The skin was closed with 6-0 Monocryl and Dermabond except on the belly button where the gauze dressing was applied. The patient tolerated the procedure well and was taken to the recovery room in excellent condition.
 
Hello, I was wondering how you decided to bill this? I am having a hard time finding much information about it. Thank you. Stephanie
 
Good morning Stephanie. I was only able to bill the 39560 since I couldn't find much info on the release of the median arcuate ligament that was accurate to what the doctor did. Thanks for your response. Michelle
 
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