amanda19791
Networker
Help!!
Patient had a cyst on spleen and provider excise cyst. I need help with coding ; my provider use 38120. See OP note.
Description of Procedure:
The patient was brought to the operating room laid in the supine position. After induction by anesthesia, the patient was placed into a modified lateral position with right side down. The patient was sterilely prepped and draped in a standard fashion. An infraumbilical incision was created and dissection carried down to the level of the fascia which was elevated and incised. An optical entry port was introduced into the abdominal cavity which was insufflated without difficulty. A camera was introduced into the abdominal cavity. Inspection revealed no injury upon entry. 2 additional 5 mm ports were placed, one in the left lower quadrant and one in the right upper quadrant. Significant bloody ascites was noted, though the blood had a distinct appearance of hemosiderin and indicating that it was not likely to have come from hemorrhage today. Utilizing a suction-irrigation device, the ascites was withdrawn from the abdominal cavity. In total, 1800 mL of bloody ascites was removed. The liver appeared normal. The bowel appeared normal. The spleen was identified with a ruptured cyst that it completely decompressed. A LigaSure device was utilized to divide the adherent omentum from the cyst. The cyst was examined and noted to be removed from the hilum of the spleen. The LigaSure device was able to be utilized to excise the splenic cyst leaving only a small portion of exposed splenic tissue but taking a portion of the spleen in order to safely remove it with hemostasis. Noting hemostasis, the omentum was placed into the cyst defect on the spleen. The cyst structure itself was placed into an Endo Catch bag and removed through the umbilical port site. The abdomen was again surveyed and noted to be hemostatic with very little ascites remaining. The abdomen was desufflated. The ports were removed. The fascia at the umbilicus was closed with Vicryl suture. The fascia at the left lower quadrant 5 mm port was closed with a Vicryl suture. Monocryl sutures utilized in a subcuticular fashion to close the skin incisions. Dermabond was applied externally.
Patient had a cyst on spleen and provider excise cyst. I need help with coding ; my provider use 38120. See OP note.
Description of Procedure:
The patient was brought to the operating room laid in the supine position. After induction by anesthesia, the patient was placed into a modified lateral position with right side down. The patient was sterilely prepped and draped in a standard fashion. An infraumbilical incision was created and dissection carried down to the level of the fascia which was elevated and incised. An optical entry port was introduced into the abdominal cavity which was insufflated without difficulty. A camera was introduced into the abdominal cavity. Inspection revealed no injury upon entry. 2 additional 5 mm ports were placed, one in the left lower quadrant and one in the right upper quadrant. Significant bloody ascites was noted, though the blood had a distinct appearance of hemosiderin and indicating that it was not likely to have come from hemorrhage today. Utilizing a suction-irrigation device, the ascites was withdrawn from the abdominal cavity. In total, 1800 mL of bloody ascites was removed. The liver appeared normal. The bowel appeared normal. The spleen was identified with a ruptured cyst that it completely decompressed. A LigaSure device was utilized to divide the adherent omentum from the cyst. The cyst was examined and noted to be removed from the hilum of the spleen. The LigaSure device was able to be utilized to excise the splenic cyst leaving only a small portion of exposed splenic tissue but taking a portion of the spleen in order to safely remove it with hemostasis. Noting hemostasis, the omentum was placed into the cyst defect on the spleen. The cyst structure itself was placed into an Endo Catch bag and removed through the umbilical port site. The abdomen was again surveyed and noted to be hemostatic with very little ascites remaining. The abdomen was desufflated. The ports were removed. The fascia at the umbilicus was closed with Vicryl suture. The fascia at the left lower quadrant 5 mm port was closed with a Vicryl suture. Monocryl sutures utilized in a subcuticular fashion to close the skin incisions. Dermabond was applied externally.