Take down of splenic flexure and hole in fascia closed

Tammy Hale

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Hello. Sorry this is so long but wanted to include what I thought was important. Please help with coding suggestions. I found take down of splenic flexure but only when in adidtion to colectomy, which was not done. It looks like the main procedure was repair of the wound. Is that 13100? I do not have the measurement for repair.

This patient was stabbed and taken to OR for the following dictated procedures: 1) laparoscopy with emergency open laparotomy, 2) take down of splenic flexure and 3) evacuation of hemoperitoneum. In the dictation it says: There was no injury to the stomach. The lesser sac was opened and a small hole was found within the omentum. Lesser sac was explored and some adhesions were taken down but no retroperitoneal hematoma was seen. The splenic flexure of the colon was taken down to inspect the colon. This all looked good. The bowel was ran without injury to the bowel.

The hole in the posterior fascia was then closed using 1-0 PDS in a
figure-of-eight. The wound continued to ooze. The wound was then opened
up. We then extended the wound into the midline incision to get down to
the muscle. Hemorrhaging was controlled with Bovie cautery. The abdomen
was then irrigated out. There were no other signs of bleeding. The fascia
was closed using a 1-0 looped PDS from above and below and tied in the
middle. Skin was closed using staples.

THANK YOU!!!
 

Treetoad

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I don't have my books with me, but there's a procedure code for exploration of an abdominal would due to trauma, such as gunshot, stabbing, etc...It would be located in the musculoskeletal section. It would also include repair of internal organs and/or foreign body removal. The procedure code begins with 20---.

I hope this is of some help to you.
 
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49000

Treetoad ... 20102 Wound exploration for trauma (stab wound) guidelines read in part (CPC 2008 Professional edition, page 75) ... "If a repair is done to major structure(s) ... requiring ... laparotomy, then those specific codes would supercede the use of codes 20100-20103." Emphasis added by FTB.

So, since they did an open lap I think 49000 is the way to go.

F Tessa Bartels, CPC, CPC-E/M
 
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