TnRushFan
Guru
Good morning,
Please see below scrubbed highlights from my operative note.
Does the aborted procedure bundle into the completed procedure? I would usually think so but both hernia procedures have distinctly separate CPT codes as well as DX codes.
Any thoughts are appreciated...thanks in advance.
POSTOPERATIVE DIAGNOSES:
1. Left inguinal hernia.
2. Recurrent right inguinal hernia.
PROCEDURE:
1. Laparoscopic left inguinal hernia repair.
2. Attempted right inguinal hernia repair.
LEFT - Sequenced as primary procedure
49560-LT
C1781 [mesh]
K40.90 New Inguinal hernia
D17.6 Cord Lipoma
-- was dissected laterally
-- dissected out a large cord lipoma [no pathology]
-- cleared off the internal ring on the left side.
-- placing a left-sided laparoscopic ProGrip mesh
RIGHT -Sequenced as secondary procedure due to reduction of services [NCCI edits]
49651-53-51-RT
K40.91 Recurrent Inguinal Hernia
K91.61 Intraoperative Hemorrhage during digestive procedure
K66.0 Adhesions
Z53.8 Procedure not carried out
-- placed our balloon dissector
-- the right side was not dissected very well
-- peritoneum was densely adherent to the abdominal wall
-- there was some bleeding from numerous small vessels
-- tried to take down the connective tissue from the right inferior epigastric.
--did incur some bleeding… had to be controlled by ligating the inferior epigastric vein between clips.
--then could not visualize the hernia defect at this point
-- Right inguinal hernia repair was aborted
Please see below scrubbed highlights from my operative note.
Does the aborted procedure bundle into the completed procedure? I would usually think so but both hernia procedures have distinctly separate CPT codes as well as DX codes.
Any thoughts are appreciated...thanks in advance.
POSTOPERATIVE DIAGNOSES:
1. Left inguinal hernia.
2. Recurrent right inguinal hernia.
PROCEDURE:
1. Laparoscopic left inguinal hernia repair.
2. Attempted right inguinal hernia repair.
LEFT - Sequenced as primary procedure
49560-LT
C1781 [mesh]
K40.90 New Inguinal hernia
D17.6 Cord Lipoma
-- was dissected laterally
-- dissected out a large cord lipoma [no pathology]
-- cleared off the internal ring on the left side.
-- placing a left-sided laparoscopic ProGrip mesh
RIGHT -Sequenced as secondary procedure due to reduction of services [NCCI edits]
49651-53-51-RT
K40.91 Recurrent Inguinal Hernia
K91.61 Intraoperative Hemorrhage during digestive procedure
K66.0 Adhesions
Z53.8 Procedure not carried out
-- placed our balloon dissector
-- the right side was not dissected very well
-- peritoneum was densely adherent to the abdominal wall
-- there was some bleeding from numerous small vessels
-- tried to take down the connective tissue from the right inferior epigastric.
--did incur some bleeding… had to be controlled by ligating the inferior epigastric vein between clips.
--then could not visualize the hernia defect at this point
-- Right inguinal hernia repair was aborted