lucygort1980
New
Can some one help me with this Op note?
Should I bill 48150 and 49320 or should I use unlisted code 48999 compared to 48150?
Thank you
PREOPERATIVE DIAGNOSIS:
Insulinoma in the head of the pancreas.
POSTOPERATIVE DIAGNOSIS:
Insulinoma in the head of the pancreas.
PROCEDURE PERFORMED:
1. Diagnostic laparoscopy.
2. Resection of common hepatic artery lymph node (frozen section is negative).
3. Robotic pancreatoduodenectomy.
4. Robotic cholecystectomy.
5. Resection of additional margin of pancreas (for permanent section).
DESCRIPTION OF PROCEDURE:
Dr. R, also Dr. I was present in the operating room. Dr. R nd I were co-surgeons in this operation. Dr. R began the operation after the trocars were placed and initial dissection was begun after the diagnostic laparoscopy confirmed that there were no unexpected findings. I came to the operating room, and with Dr. then we did extend the Kocher maneuver, mobilized the proximal jejunum, carried the dissection down along the common hepatic artery, clipped the gastroduodenal artery twice, proximally and distally divided it, and then opened up the gastrocolic omentum, carried the dissection to the duodenum, transected the duodenum with robotic stapling device, and then dividing the proximal jejunum with robotic stapling device. We then lifted the pancreas up off the superior mesenteric vein and portal vein, and carried the dissection from the division of the jejunum to the edge of the portal vein, making sure not to injure any major branches or significant veins, and as well to make sure we did not injure the superior mesenteric artery and arterial supply to the small bowel, colon, and viscera.
There was a large gastroepiploic vein coming off the portal vein. This was divided after numerous applications of the vessel sealing device, and then divided a bit closure to the pylorus.
Pancreas was divided with hook cautery over the superior mesenteric and portal vein, and dissection was carried up, the common hepatic duct was transected, the gallbladder was removed. This was all then placed into a specimen bag after the specimen was cleanly, nicely without blood loss separated from the superior mesenteric artery and portal vein.
The specimen was placed into an extraction bag and Dr. I and Dr. marked this. Dr. carried it to Pathology. I went over the specimen with Pathology while Dr. had gone. I did biliojejunal anastomosis and the pancreaticojejunostomy. The biliary jejunostomy was undertaken with running 4-0 Prolene, knot on the outside. I started looking at the duct at 9 0'clock, knots on the outside, ran the posterior layer and started at 9 0'clock, ran the ventral layer, and then tied the sutures at 3 o'clock to each other making sure as best I could that I pulled the snug but did not pursestring it too tight. Before doing the anastomosis, I opened it up along the ventral surface of the bile duct to make sure that we had good size of anastomosis as we possibly and safely would do.
I did pancreaticojejunostomy with posterior layer of running 3-0 barbed suture called V-Loc. I then did 4 sutures small duct to small hole in bowel anastomosis using V-Loc sutures. The pancreatic duct was probably on the order of a 1.5 mm, very small, and around the ventral layer of this anastomosis with running V-Loc suture, tying the sutures together at the caudal aspect of the anastomosis. I inspected this at looked great. I then did the duodenojejunostomy by identifying the jejunum distal to the ligament of Treitz, bringing it up to the end of the duodenum, the staple line on the duodenum, which removed. A jejunotomy was made and 1 layer with 9-inch V-Loc suture anastomosis was made, looking at the duodenum at 9 o'clock, carrying it to the posterior layer, leaving the suture at 3 0'clock, running a ventral layer, and then starting again at 9 o'clock, and then having the sutures together at 3 0'clock and tying them.
Dr. then inspected the anastomosis, everything looked great. She placed couple of additional sutures into the duodenojejunostomy for security and to take tension off the anastomosis particularly by placing suture from the lesser curve of the stomach to the jejunum, and then along the greater curve to the jejunum so that the afferent and efferent limbs did not have any tension on them with regard to the anastomosis. She inverted the end of the jejunum of the staple line with a pursestring of suture using V-Loc suture. She reconstructed the ligament of Treitz, copiously irrigated, and then the trocar sites were closed with Maxon, followed by Steri-Strips including our extraction site, which was in the right lower quadrant.
Should I bill 48150 and 49320 or should I use unlisted code 48999 compared to 48150?
Thank you
PREOPERATIVE DIAGNOSIS:
Insulinoma in the head of the pancreas.
POSTOPERATIVE DIAGNOSIS:
Insulinoma in the head of the pancreas.
PROCEDURE PERFORMED:
1. Diagnostic laparoscopy.
2. Resection of common hepatic artery lymph node (frozen section is negative).
3. Robotic pancreatoduodenectomy.
4. Robotic cholecystectomy.
5. Resection of additional margin of pancreas (for permanent section).
DESCRIPTION OF PROCEDURE:
Dr. R, also Dr. I was present in the operating room. Dr. R nd I were co-surgeons in this operation. Dr. R began the operation after the trocars were placed and initial dissection was begun after the diagnostic laparoscopy confirmed that there were no unexpected findings. I came to the operating room, and with Dr. then we did extend the Kocher maneuver, mobilized the proximal jejunum, carried the dissection down along the common hepatic artery, clipped the gastroduodenal artery twice, proximally and distally divided it, and then opened up the gastrocolic omentum, carried the dissection to the duodenum, transected the duodenum with robotic stapling device, and then dividing the proximal jejunum with robotic stapling device. We then lifted the pancreas up off the superior mesenteric vein and portal vein, and carried the dissection from the division of the jejunum to the edge of the portal vein, making sure not to injure any major branches or significant veins, and as well to make sure we did not injure the superior mesenteric artery and arterial supply to the small bowel, colon, and viscera.
There was a large gastroepiploic vein coming off the portal vein. This was divided after numerous applications of the vessel sealing device, and then divided a bit closure to the pylorus.
Pancreas was divided with hook cautery over the superior mesenteric and portal vein, and dissection was carried up, the common hepatic duct was transected, the gallbladder was removed. This was all then placed into a specimen bag after the specimen was cleanly, nicely without blood loss separated from the superior mesenteric artery and portal vein.
The specimen was placed into an extraction bag and Dr. I and Dr. marked this. Dr. carried it to Pathology. I went over the specimen with Pathology while Dr. had gone. I did biliojejunal anastomosis and the pancreaticojejunostomy. The biliary jejunostomy was undertaken with running 4-0 Prolene, knot on the outside. I started looking at the duct at 9 0'clock, knots on the outside, ran the posterior layer and started at 9 0'clock, ran the ventral layer, and then tied the sutures at 3 o'clock to each other making sure as best I could that I pulled the snug but did not pursestring it too tight. Before doing the anastomosis, I opened it up along the ventral surface of the bile duct to make sure that we had good size of anastomosis as we possibly and safely would do.
I did pancreaticojejunostomy with posterior layer of running 3-0 barbed suture called V-Loc. I then did 4 sutures small duct to small hole in bowel anastomosis using V-Loc sutures. The pancreatic duct was probably on the order of a 1.5 mm, very small, and around the ventral layer of this anastomosis with running V-Loc suture, tying the sutures together at the caudal aspect of the anastomosis. I inspected this at looked great. I then did the duodenojejunostomy by identifying the jejunum distal to the ligament of Treitz, bringing it up to the end of the duodenum, the staple line on the duodenum, which removed. A jejunotomy was made and 1 layer with 9-inch V-Loc suture anastomosis was made, looking at the duodenum at 9 o'clock, carrying it to the posterior layer, leaving the suture at 3 0'clock, running a ventral layer, and then starting again at 9 o'clock, and then having the sutures together at 3 0'clock and tying them.
Dr. then inspected the anastomosis, everything looked great. She placed couple of additional sutures into the duodenojejunostomy for security and to take tension off the anastomosis particularly by placing suture from the lesser curve of the stomach to the jejunum, and then along the greater curve to the jejunum so that the afferent and efferent limbs did not have any tension on them with regard to the anastomosis. She inverted the end of the jejunum of the staple line with a pursestring of suture using V-Loc suture. She reconstructed the ligament of Treitz, copiously irrigated, and then the trocar sites were closed with Maxon, followed by Steri-Strips including our extraction site, which was in the right lower quadrant.