I am sooooo fortunate in that most of the coding I do for OB/GYN doesn't result in the type of problems that force the doc back to the operating room. While that's awesome, it doesn't give me a lot of practice for when it is necessary. I was hoping for some guidance on this op note.
OP NOTE
Date of Procedure: 3/15/2015
Preop & Postop Dx: Postoperative hemorrhage secondary to anticoagulation
Procedure: 1. Exploratory Laparotomy
2. Evacuation of intraperitoneal Blood
INDICATIONS: The patient is a 52-year-old female who, on postoperative day #3 had acute onset of hypotension and tachycardia. The patient's hemoglobin, which had been stable on the previous postoperative days at approximately 11, had dropped to 8. The patient was volume resuscitated with crystalloids and albumin and improved blood pressure and pulse was lowered. The patient was complaining of severe back pain. The onset of symptoms began after the patient had a bowel movement. Prior to receiving the ordered packed red blood cells, the patient again became hypotensive, tachycardic and nonresponsive and ultimately went into pulseless electrical activity at which time a code blue was initiated. The patient was easily resuscitated with intubation and a single defibrillation at 200 joules. Due to the patient's instability, the patient was taken immediately to the operating room.
FINDINGS: Blood and clot, 200mL, intraperitoneally mostly dark red blood. A large right pelvic sidewall organized clot of approximately 300mL was identified. The bilateral ovarian arteries/infundibulopelvic ligaments were hemostatic with normal cautery effect and no active bleeding. Peritoneal surfaces in the bilateral ovarian fossa were oozing slightly, but no acute bleeding was noted.
TECHNICAL DESCRIPTION: The patient was taken to the operating room where general anesthesia was induced. The staples were removed from the skin using scissors, the previously placed 0-looped Maxon was cut out. A large amount of dark red blood appreciated from the abdomen upon opening the incision. The blood and clot were quickly evacuated and the patient was placed in slight Trendelenburg. The bowel was packed away with moistened laparotomy sponges/ The pelvic was suction and blood and clot were removed with laparotomy sponges.
Once the intraperitoneal clot was completely evacuated, the pelvic was then closely inspected and the infundibulopelvic ligaments were identified bilaterally and noted to be hemostatic with appropriate cautery effect. There was no active bleeding noted from these sites. There was some oozing in the bilateral ovarian fossa along the peritoneal surfaces; however, no profuse or active bleeding was noted from above. Hemostasis was then achieved with cautery along the slightly oozing peritoneal edges as well as the anterior peritoneum near the bladder. FloSeal was also placed along these areas with pressure applied. There was no active bleeding noted after continued monitoring and observation over several minutes.
The rest of the op note goes about explaining the routine re-approximation and closure. I first began with CPT 49002. However, upon looking more, I wondered if 35840 might be more appropriate. The modifier 78 would be attached to either code.
With regards to the diagnosis, my question came when assigning a code to the tachycardia. I was thinking 998.01, as the op note from the procedure done 3 days prior, lists post-op shock as a diagnosis. However due to this occurring 3 days post-op I questioned whether that would be appropriate.
A little guidance would be so much appreciated. At this point, I'm overthinking everything. Thank you so much for your time!!!!!!
OP NOTE
Date of Procedure: 3/15/2015
Preop & Postop Dx: Postoperative hemorrhage secondary to anticoagulation
Procedure: 1. Exploratory Laparotomy
2. Evacuation of intraperitoneal Blood
INDICATIONS: The patient is a 52-year-old female who, on postoperative day #3 had acute onset of hypotension and tachycardia. The patient's hemoglobin, which had been stable on the previous postoperative days at approximately 11, had dropped to 8. The patient was volume resuscitated with crystalloids and albumin and improved blood pressure and pulse was lowered. The patient was complaining of severe back pain. The onset of symptoms began after the patient had a bowel movement. Prior to receiving the ordered packed red blood cells, the patient again became hypotensive, tachycardic and nonresponsive and ultimately went into pulseless electrical activity at which time a code blue was initiated. The patient was easily resuscitated with intubation and a single defibrillation at 200 joules. Due to the patient's instability, the patient was taken immediately to the operating room.
FINDINGS: Blood and clot, 200mL, intraperitoneally mostly dark red blood. A large right pelvic sidewall organized clot of approximately 300mL was identified. The bilateral ovarian arteries/infundibulopelvic ligaments were hemostatic with normal cautery effect and no active bleeding. Peritoneal surfaces in the bilateral ovarian fossa were oozing slightly, but no acute bleeding was noted.
TECHNICAL DESCRIPTION: The patient was taken to the operating room where general anesthesia was induced. The staples were removed from the skin using scissors, the previously placed 0-looped Maxon was cut out. A large amount of dark red blood appreciated from the abdomen upon opening the incision. The blood and clot were quickly evacuated and the patient was placed in slight Trendelenburg. The bowel was packed away with moistened laparotomy sponges/ The pelvic was suction and blood and clot were removed with laparotomy sponges.
Once the intraperitoneal clot was completely evacuated, the pelvic was then closely inspected and the infundibulopelvic ligaments were identified bilaterally and noted to be hemostatic with appropriate cautery effect. There was no active bleeding noted from these sites. There was some oozing in the bilateral ovarian fossa along the peritoneal surfaces; however, no profuse or active bleeding was noted from above. Hemostasis was then achieved with cautery along the slightly oozing peritoneal edges as well as the anterior peritoneum near the bladder. FloSeal was also placed along these areas with pressure applied. There was no active bleeding noted after continued monitoring and observation over several minutes.
The rest of the op note goes about explaining the routine re-approximation and closure. I first began with CPT 49002. However, upon looking more, I wondered if 35840 might be more appropriate. The modifier 78 would be attached to either code.
With regards to the diagnosis, my question came when assigning a code to the tachycardia. I was thinking 998.01, as the op note from the procedure done 3 days prior, lists post-op shock as a diagnosis. However due to this occurring 3 days post-op I questioned whether that would be appropriate.
A little guidance would be so much appreciated. At this point, I'm overthinking everything. Thank you so much for your time!!!!!!
