CJMorrison
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Below is an operative report from a surgeon I do billing for. He likes to code his own surgeries. I need an opinion about how he coded this surgery. I have also looked on the hospital side to see how they coded the surgery and it is different.
OPERATIVE DESCRIPTION: He was consented for the above stated operations, understanding the risk involved, including risk of bleeding, infection, injury to the intestines . He has an allergy to Teramycin and Penicillin , was given Clindamycin 900 mgs. iv in the proper perioperative period and brought to the OR and placed in supine position. Bilateral SCDs were placed on the lower extremities and the patient underwent general anesthesia by endotracheal tube intubationwithout complications. Time out was held and the patient was correctly identified with two independent identifiers as well as the operative procedure.
A 50/50 mixture of 1% Lidocaine , 025% marcarine was injected at the incision sites using a total of 40 ml. I went through his old previous incision at the umbilicus and removed some old scar and sent that off for histopathological examination. I dissected down till I found the mesh. I was able to grasp the mesh and in a piecemeal fashion excised it from surrounding tissue. I noticed on the right lateral side there was a hernia sac, also one on the left lateral side. Once I was able to free the adhesions from around the mesh up, I brought it out and sent it for histopathological examination and removed any further adhesions down around the previous incision. I then placed a balloon tip 11 mm port. I inflated the balloon and started insufflation to a total of 15 mm/mercury. Then I
placed a 30 degree 5 mm laparoscope within the peritoneal cavity and inspected it. There was no immediate abnormalities found, so I had the patient placed in Trendelenburg with rotation to his right and there in the left lower quadrant, at the previous mesh site could see some adhesions at the epiploica fat from the sigmoid colon to the previous peritoneal closure site which had been closed with protector staples . I then placed a 5 mm port in the left lower quadrant under direct visualization and then using a combination of blunt/sharp dissection removed the adhesions making sure that there was no injury to the colon . We had excellent hemostasis at the end of this case. There were three exposed Protack metal corkscrew staples which I was able to remove so that there would be no further adhesions and we sent those with the mesh specimen.
After verifying excellent hemostasis and that there were no other adhesions, especially on the right side and there was recurrence of his inguinal hernias, we then placed the patient back in supine position, stopped insufflation , removed the ports and gave the patient three deep breaths to remove any excess gas . At that point I then isolated the hernia sac on the right lateral side and excised that and then isolated the hernia sac on the left lateral side and excised that. I then used a Proceed 6.4 diameter mesh and placed that within the peritoneal cavity and brought it up through the incisional defect so that it expanded properly. I verified that we had proper expansion and then sutured the mesh in place and closed the fascia with multiple interrupted sutures of 0 PDS and finally the subcutaneous tissue was closed with running stitch of 3-0 Vicryl and finally the skin was re-approximated using a running subcuticular stitch of 4-0 Vicryl. I had both the incisional hernia site and the left lower quadrant 5 mm port site. A sterile dressing was applied externally and the patient was awakened , extubated and transferred to the recovery room in stable condition.
These are the codes the doctor used:
Diagnosis code: 553.21
Procedure codes: 49402 Removal of peritoneal foreign body from peritoneal cavity
49565 Repair recurrent incisional or ventral hernia; reducible
49568 Inplantation of mesh or other prosthesis
The hospital coded:
Diagnosis code: 553.21
Procedure code: 49656 Laparoscopy, surgical, repair recurrent incisional hernia (includes mesh insertion, when performed); reducible.
I need an opinion please! Thank you in advance for any help given.
OPERATIVE DESCRIPTION: He was consented for the above stated operations, understanding the risk involved, including risk of bleeding, infection, injury to the intestines . He has an allergy to Teramycin and Penicillin , was given Clindamycin 900 mgs. iv in the proper perioperative period and brought to the OR and placed in supine position. Bilateral SCDs were placed on the lower extremities and the patient underwent general anesthesia by endotracheal tube intubationwithout complications. Time out was held and the patient was correctly identified with two independent identifiers as well as the operative procedure.
A 50/50 mixture of 1% Lidocaine , 025% marcarine was injected at the incision sites using a total of 40 ml. I went through his old previous incision at the umbilicus and removed some old scar and sent that off for histopathological examination. I dissected down till I found the mesh. I was able to grasp the mesh and in a piecemeal fashion excised it from surrounding tissue. I noticed on the right lateral side there was a hernia sac, also one on the left lateral side. Once I was able to free the adhesions from around the mesh up, I brought it out and sent it for histopathological examination and removed any further adhesions down around the previous incision. I then placed a balloon tip 11 mm port. I inflated the balloon and started insufflation to a total of 15 mm/mercury. Then I
placed a 30 degree 5 mm laparoscope within the peritoneal cavity and inspected it. There was no immediate abnormalities found, so I had the patient placed in Trendelenburg with rotation to his right and there in the left lower quadrant, at the previous mesh site could see some adhesions at the epiploica fat from the sigmoid colon to the previous peritoneal closure site which had been closed with protector staples . I then placed a 5 mm port in the left lower quadrant under direct visualization and then using a combination of blunt/sharp dissection removed the adhesions making sure that there was no injury to the colon . We had excellent hemostasis at the end of this case. There were three exposed Protack metal corkscrew staples which I was able to remove so that there would be no further adhesions and we sent those with the mesh specimen.
After verifying excellent hemostasis and that there were no other adhesions, especially on the right side and there was recurrence of his inguinal hernias, we then placed the patient back in supine position, stopped insufflation , removed the ports and gave the patient three deep breaths to remove any excess gas . At that point I then isolated the hernia sac on the right lateral side and excised that and then isolated the hernia sac on the left lateral side and excised that. I then used a Proceed 6.4 diameter mesh and placed that within the peritoneal cavity and brought it up through the incisional defect so that it expanded properly. I verified that we had proper expansion and then sutured the mesh in place and closed the fascia with multiple interrupted sutures of 0 PDS and finally the subcutaneous tissue was closed with running stitch of 3-0 Vicryl and finally the skin was re-approximated using a running subcuticular stitch of 4-0 Vicryl. I had both the incisional hernia site and the left lower quadrant 5 mm port site. A sterile dressing was applied externally and the patient was awakened , extubated and transferred to the recovery room in stable condition.
These are the codes the doctor used:
Diagnosis code: 553.21
Procedure codes: 49402 Removal of peritoneal foreign body from peritoneal cavity
49565 Repair recurrent incisional or ventral hernia; reducible
49568 Inplantation of mesh or other prosthesis
The hospital coded:
Diagnosis code: 553.21
Procedure code: 49656 Laparoscopy, surgical, repair recurrent incisional hernia (includes mesh insertion, when performed); reducible.
I need an opinion please! Thank you in advance for any help given.
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