Wiki Please help return to OR for incisional bleeding

JRuybal

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Hello. Can someone please help me to find a CPT code that fits this? I am having a hard time finding anything that fits.

We have a pt who was in for a routine low transverse C-section with BTL. She had been in stable condition. After a couple hours she was bleeding from the incision site. Within the hour bled through the pressure bandage that had been applied. Decision was made to return to OR for exploratory surgery. There was a 1 cm segment of the middle of the incision that had come apart and had clot in it. Several other parts of the incision appears to have pressure from underneath. Staples were easily removed. The wound was opened down to the level of the fascia. In the middle of the incision was large hematoma/clot that was removed with a lap sponge. Underneath, on the inferior side of the incision, was a small bleeding vessel. Bovie cautery was used to make it hemostatic. The rest of the incision was cleaned with the lap sponge. There were two small oozing areas on the left inferior side of the incision, and one on the right superior edge of the incision, also made hemostatic by bovie cautery. No blood welling up from underneath the fascia. Pressure applied to see if bleeding under the fascia which none identified. Subcutaneous suture applied to re-approximate the subcutaneous tissue. Staples used to close the skin.

Any input will be greatly appreciated.
 
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