Wiki Please Help Exploratory Laparoscopy - Multiple stab wounds to thoracoabdominal region

[bill2doc]

Multiple stab wounds to thoracoabdominal region, traumatic laceration of face 4cm

Doc notes 3 items 1. Exploratory Laparoscopy, 2. Laparoscopic Diaphragmatic Repaid 3. repair of facial laceration 4CM in Length

Midline supraumbilical incision carried down through to base of umbilicus, grasped adn end elevated. Hasson Trocar entered through defect and pneumoperitoneum was established. Laparoscope was entered into abdomen. Abdomen, bowel, transverse colon, small intestine, stomach and liver examined, no evidence of laceration. 5mm placed through stab wound indicating a small laceration in the diaphragm 1cm. Appeared to be level of mid to upper spleen region which shallow laceration of splenic pole. Diaphragmatic laceration repaired laparoscopically 0 silk suture was introduced through port. left upper quadrant irrigated until clear. Abdomen again examined, no further injury. ports removed. Skin closed in subcuticular fashion using 4-0 Vicryl

Any anyone please help with CPT code for this.... Thank you so much!

 

[TonyaMichelle]

The only code that I came closest to for the laparoscopic repair of the diaphram laceration is:

32654 (Thoracoscopy, surgical; with control of hemorrhage)
I am almost sure that a stab wound to the chest cavity causes hemorrhage and in order to stop the hemorrhage, you will have to repair the laceration.

For the traumatic facial laceration, I would need to know more for example (did it need debriding?, was it a simple, intermediate or complex closure? or, did she need any skin grafting?)

Hope this helps