Need advice on whether or not to use the unlisted intestine procedure code for oversew of anastomosis. There was bleeding at the anastomotic site with mild separation of the anastomosis one day post op.
POSTPROCEDURE DIAGNOSIS:
1. Rectal Bleeding
2. Myelodysplasia
DESCRIPTOIN OF PROCEDURE:
The patient was brought to the operating room after proper identification, confirmation, and PARQ. After adequate general anesthesia and preoperative antiboitics, the patient was placed in the prone jackknife position. Patient was then prepped and draped in the normal sterile fashion. The anal canal was then inspected. We identified a mild separation of the left side of the anastomosis with no significant clot formation. The wound was then irrigated with copious amounts of normal saline. The anastomosis had bleeding at the bleeding edges. This was controlled with electrocautery. The anastomosis was irrigated copiously with normal slaine. The space between the anastomosis and the retrorectal space was also inspected for hemostasis. There was good control of the hemostasis. The anastomosis was then reinforced with interrupted 2-0 Vicryl in a separated fashion easily recreating the anastomosis and a complete formation. The anastomosis was inspected numerous times for any signs of any bleeding. At the end of the procedure and after repair of the anastomosis, there was no evidence of any bleeding. The operation was terminated. The wound was then irrigated with normal saline, inspected circumferentially for any signs of any problems with the anastomosis and there was none. There was no further bleeding and the operation was terminated.
Is 998.31 with cpt: 44799 appropriate?
POSTPROCEDURE DIAGNOSIS:
1. Rectal Bleeding
2. Myelodysplasia
DESCRIPTOIN OF PROCEDURE:
The patient was brought to the operating room after proper identification, confirmation, and PARQ. After adequate general anesthesia and preoperative antiboitics, the patient was placed in the prone jackknife position. Patient was then prepped and draped in the normal sterile fashion. The anal canal was then inspected. We identified a mild separation of the left side of the anastomosis with no significant clot formation. The wound was then irrigated with copious amounts of normal saline. The anastomosis had bleeding at the bleeding edges. This was controlled with electrocautery. The anastomosis was irrigated copiously with normal slaine. The space between the anastomosis and the retrorectal space was also inspected for hemostasis. There was good control of the hemostasis. The anastomosis was then reinforced with interrupted 2-0 Vicryl in a separated fashion easily recreating the anastomosis and a complete formation. The anastomosis was inspected numerous times for any signs of any bleeding. At the end of the procedure and after repair of the anastomosis, there was no evidence of any bleeding. The operation was terminated. The wound was then irrigated with normal saline, inspected circumferentially for any signs of any problems with the anastomosis and there was none. There was no further bleeding and the operation was terminated.
Is 998.31 with cpt: 44799 appropriate?
