ksrkelly7
Networker
Hi all,
I am having a dispute with one of my trauma surgeons regarding unbundling. He billed CPT 49000 and 20102 for the following surgery. CCI edits have a 1 for the 20102. I think he should only bill the 49000, but he disagrees. Any thoughts?
Indication for Surgery
Gunshot wound to the left lower flank
Preoperative Diagnosis
Same
Postoperative Diagnosis
Gunshot wound to the left lower flank with moderate size rectus sheet hematoma
Operation
#1 exploratory laparotomy
#2 exploration of gunshot wound debridement and irrigation
Anesthesia
Gen. endotracheal anesthesia
Estimated Blood Loss
Minimal
Urine Output
Not applicable
Findings
Rectus sheath hematoma of the right side no violation of the intra-abdominal cavity.
Specimen(s)
None
Complications
None
Technique
This is a 29-year-old gentleman with a single gunshot wound to the left lower flank entrance wound is on the anterior abdomen exit wound posterior flank. Patient came hemodynamically stable however increased abdominal pain in the trauma resuscitation room necessitating exploratory laparotomy for the possibility of violation of the abdominal domain. Patient was taken urgently to the operative theater placed in supine position surgical timeout was done to identify patient location as well as operation be done. Perioperative antibiotics were administered. A midline incision was then made the abdomen was entered upon entering the abdomen there is no evidence of blood or violation of the anterior abdominal wall. The cecum was evaluated with no evidence of any injury. The wounds were explored no evidence of violation of the intra-abdominal domain via exploration of the wounds. The wounds were copiously irrigated with Betadine soaked irrigation. The abdomen was closed with running looped PDS. Prior to closure sponge and needle counts were correct ?2. The skin was approximated using staples. Patient tolerated procedure well and returned to recovery extubated in stable condition.
Surgical Sweep Complete (Yes/No/Not Applicable)
Yes
Disposition
PACU
Follow up plan
Admit to medical surgical floor for further evaluation and resuscitation.
Thanks for your help,
Kelly
I am having a dispute with one of my trauma surgeons regarding unbundling. He billed CPT 49000 and 20102 for the following surgery. CCI edits have a 1 for the 20102. I think he should only bill the 49000, but he disagrees. Any thoughts?
Indication for Surgery
Gunshot wound to the left lower flank
Preoperative Diagnosis
Same
Postoperative Diagnosis
Gunshot wound to the left lower flank with moderate size rectus sheet hematoma
Operation
#1 exploratory laparotomy
#2 exploration of gunshot wound debridement and irrigation
Anesthesia
Gen. endotracheal anesthesia
Estimated Blood Loss
Minimal
Urine Output
Not applicable
Findings
Rectus sheath hematoma of the right side no violation of the intra-abdominal cavity.
Specimen(s)
None
Complications
None
Technique
This is a 29-year-old gentleman with a single gunshot wound to the left lower flank entrance wound is on the anterior abdomen exit wound posterior flank. Patient came hemodynamically stable however increased abdominal pain in the trauma resuscitation room necessitating exploratory laparotomy for the possibility of violation of the abdominal domain. Patient was taken urgently to the operative theater placed in supine position surgical timeout was done to identify patient location as well as operation be done. Perioperative antibiotics were administered. A midline incision was then made the abdomen was entered upon entering the abdomen there is no evidence of blood or violation of the anterior abdominal wall. The cecum was evaluated with no evidence of any injury. The wounds were explored no evidence of violation of the intra-abdominal domain via exploration of the wounds. The wounds were copiously irrigated with Betadine soaked irrigation. The abdomen was closed with running looped PDS. Prior to closure sponge and needle counts were correct ?2. The skin was approximated using staples. Patient tolerated procedure well and returned to recovery extubated in stable condition.
Surgical Sweep Complete (Yes/No/Not Applicable)
Yes
Disposition
PACU
Follow up plan
Admit to medical surgical floor for further evaluation and resuscitation.
Thanks for your help,
Kelly
