LaceyCanon
Networker
Provider wants to bill 46700 & 44615. My problem is the 44615 onvolves an abdominal incision and his note does not seem to describe this procedure.
See op note:
NARRATIVE:
The patient was brought back to the operating room and placed in supine
position, and general endotracheal anesthesia was performed. The patient was
then placed in a prone jack-knife position, and the buttocks were taped in
place. The perineum was prepped and draped in the usual sterile fashion. The
patient did receive preop antibiotics and SCDs. At this point, I used 1%
lidocaine with epinephrine for local block. I evaluated the anal canal. In
the anal canal was a severe amount of scar tissue. I could palpate the
muscle. I then made an incision into the scar tissue and removed some scar
tissue. I then, with dilators, dilated the area and then also finger dilated.
I then got into a space where there was just scar tissue and fat. It appeared
that the anastomosis likely leaked and then pulled away from the anal canal.
I continued dissection. This was a very difficult dissection, as the anal
canal was scarred, and the viewing area was very small. I was able to find
something about 2 or 3 cm up that appeared like it could be bowel. I made an
incision and found what was the colonic J-pouch, which was pulled away from
the anal canal. There was stool within it. I copiously irrigated this area
out. I circumferentially dissected around this and then was able to get a
little bit of length on the colonic J-pouch. Unfortunately, there was not as
much length as I would have liked. It did pull up toward the anus, and then I
was able to suture this up to the anal canal, but it was on a lot of tension.
I am very doubtful that this stays in place, and it unfortunately will likely
scar again. I then again removed some scar tissue on the anus. I did not
take any muscle. This was patent and open to the colonic J-pouch. Once I
finished sewing as much as I could, I copiously irrigated out the area and
placed in a Gelfoam. The patient tolerated the procedure well. He was
brought to the recovery room in stable condition.
See op note:
NARRATIVE:
The patient was brought back to the operating room and placed in supine
position, and general endotracheal anesthesia was performed. The patient was
then placed in a prone jack-knife position, and the buttocks were taped in
place. The perineum was prepped and draped in the usual sterile fashion. The
patient did receive preop antibiotics and SCDs. At this point, I used 1%
lidocaine with epinephrine for local block. I evaluated the anal canal. In
the anal canal was a severe amount of scar tissue. I could palpate the
muscle. I then made an incision into the scar tissue and removed some scar
tissue. I then, with dilators, dilated the area and then also finger dilated.
I then got into a space where there was just scar tissue and fat. It appeared
that the anastomosis likely leaked and then pulled away from the anal canal.
I continued dissection. This was a very difficult dissection, as the anal
canal was scarred, and the viewing area was very small. I was able to find
something about 2 or 3 cm up that appeared like it could be bowel. I made an
incision and found what was the colonic J-pouch, which was pulled away from
the anal canal. There was stool within it. I copiously irrigated this area
out. I circumferentially dissected around this and then was able to get a
little bit of length on the colonic J-pouch. Unfortunately, there was not as
much length as I would have liked. It did pull up toward the anus, and then I
was able to suture this up to the anal canal, but it was on a lot of tension.
I am very doubtful that this stays in place, and it unfortunately will likely
scar again. I then again removed some scar tissue on the anus. I did not
take any muscle. This was patent and open to the colonic J-pouch. Once I
finished sewing as much as I could, I copiously irrigated out the area and
placed in a Gelfoam. The patient tolerated the procedure well. He was
brought to the recovery room in stable condition.