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Rt colon resection

  1. #1
    Default Rt colon resection
    Medical Coding Books
    Pre op DX: Bowel obstruction

    Diagnostic lap was done at the beginning of the procedure. The patient was found to have what appeared to be a mass in the cecum areas causing adhesions of the sm bowel to the cecum, as well as to the right peritoneal gutter. Exploratory lap was done and the right colon was removed in it's entirety. The patient was found to have approx 10-12 cm of the terminal ileum that was adhered to the cecum, most likely from perforated colon cancer, which cause localized inflammatory changes causing adhesions which most likely sealed the erforation. The incision was closed using #1 looped PDS.

    I am not really sure where to I need more info from the doctor? If you could please help in any way, I sure would appreciate it. I know the diagnostic lap and exp lap are bundled, but what procedure code would I use?

  2. #2
    Hey girl! You need more from doc. Did he do an anastomosis or a colostomy? If you want me to look at the report send me a private message and I'll send you my email and you can scan it to me.
    adrianne, cpc

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