penswhitex
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The surgeon performed oversew of a bleeding duodenal ulcer (CPT 43840) and selective vagotomy. The question I have is with the documentation of the vagotomy. I am reading the vagotomy portion of the op note and it reads as follows: The distal vagus nerve was identified and the area of the pylorus was transected. At this point the abdomen was copiously irrigated. There was no further bleeding identified. The fascia was closed in a running fashion and the skin was closed using skin staples. Am I way off or is this not enough documentation to bill for the vagotomy also? Encoder pro has a longer description for CPT 43640. I'm not sure about CPT 64755 either. Any takers?