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Laparoscopy with evacuation of blood

  1. Question Laparoscopy with evacuation of blood
    Medical Coding Books
    Need help coding the following OP report:

    Pre-Op Dx: Postoperative bleed
    Post-Op Dx: Postoperative bleed

    Procedure: Laparoscopy with evacuation of blood

    A Hasson catheter was introduced and the abdominal cavity was insufflated with carbon dioxide gas. A second 5mm triocar was placed in the previous LLQ trocar site, and a third 5mm trocar was ultimately placed in the midline. The abdominal cavity had a significant amount of blood that appeared old as well as a clot present. this was aspirated but all that appeared old. There was no active bright red bleeding. The spleen,liver, pelvis, and fallopian tubes was insepected and found unremarkable. the most likely source of bleeding was the omentum that had been previously taken down from the abdominal wall. There was clot present adherent to omentum. This was cleared with no active bleeding present. There was no evidence of any active bleeding or oozing within theabdomen. A drain was placed abutting the omentum and the most likely site of the bleed.

    Any help would be greatly appreciated.
    Sonja Little, CPC

  2. Default Any sugesstions
    Does Anyone have any sugesstions?? I am think 49322, maybe?
    Sonja Little, CPC

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