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Thread: The most complicated 2-paragraph op report EVER.

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    Question The most complicated 2-paragraph op report EVER.

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    OK, A total hip arthroplasty is being done on a 90 yr old woman (??). During this op, she starts bleeding out. There are no vascular sugeons available (this is a rural hospital and there are unfortunates gaps in the specialist call schedules), so my Doc, who is a General Surgeon, is called in to help. She sutures an artery, which she specifies is not the main femoral artery, but an "offshoot" of the main femoral. The wound is completely dry at this point, so she leaves and the hip replacement continues. That was paragraph 1.

    In paragraph 2, she's called back in because there's more bleeding. This time the bleeding points are less specific, and she performs an exploration of the groin area and starts putting in clamps and sutures. Sometime during this portion a vascular surgeon arrives and pitches in as well. She does not specify what points are sutured and/or clamped, and the Vascular surgeon didn't dictate anything at all. Per the orthopedic surgeon's dictation he must have been standing in a corner with his fingers in his ears because he didn't see or hear anything while the other surgeons were in the room. His dicatation barely mentions them.

    Obviously my Doc needs to dictate in more detail, but I'm not sure what to tell her. I don't even know what I need to know! Part of the problem is that all the vascular codes specify extremity or abdomen, and she refers to the groin area through the whole op report. It's a hip replacement, so I went with extremity codes.

    Here are some codes that I've managed to find that meet SOME of the criteria I have.

    Paragraph 1:
    37618 - Ligation, major artery, extremity. (IS it a major artery?)
    35226 - Repair blood vessel, direct, lower extremity (not sure ligation constitutes repair)

    Paragraph 2:
    35860 - Exploration for postoperative hemorrhage, extremity (not post op, tho)
    35761 - exploration not followed by surgical repair, with or without lysis of artery, other vessels. (not sure exploration of vessels applies. It was more like exploration LOOKING FOR vessels.)

    Any assistance would be helpful; vascular surgery coding is not something I'm particularly familiar with.


  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    I can't offer any help with the coding, but maybe she doesn't realize the codes in the CPT book. May be as simple as asking her for help, and hopefully she is approachable. Just explain how specific the codes are in the book about what exactly was sutured and if she could help you narrow down the right codes. You know most surgeons love to be asked questions and show off their incredible brain power

    on the "exploration" however...(p#2) I think you'll end up coding any actual repair she's done, and the "exploration" will be built in.
    35761 specifies NO surgical repair is done to the vessel itself. (like looking for an "injured" vesssel and finding it is being compressed by scar tissue, so you work on the tissue and not the vessel itself)

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