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Need another opinion

  1. #1
    Question Need another opinion
    Medical Coding Books
    I am confused by the end of this op report and would like another opinion before I go back to the doctor with it. Maybe its just me and the note is fine.

    PROCEDURE: Laparoscopic converted to open repair of hiatal
    hernia with toupee fundoplication and gastropexy, splenic biopsy.

    Ok, hernia repair and all that is fine, splenic biopsy is the confusing part.

    From the body of the op report

    During the course of exploration, there was found
    to be an abnormal appearing pole of the kidney with a hard mass
    there. This was taken as a biopsy and after achieving adequate
    splenic hemostasis, the abdomen was then closed using a 32 looped
    PDS and skin staples.

    To me, I am reading biopsy of kidney, 50205, not spleen. Does this look like clarification is needed to anyone else?


    Laura, CPC, CPMA, CEMC

  2. #2
    Ellenville, New York
    Default Agree - query
    It does appear that the biopsy was taken from the kidney, not the spleen from this documentation. Agree with you - you do need clarification from the doctor.

  3. #3
    Default Thanks!
    I sent it back to him earlier today, will probably get my head bitten off tomorrow for questioning him.

    Oh well, one of many job hazards we coders face daily!

    Laura, CPC, CPMA, CEMC

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