Results 1 to 4 of 4

Unsure how to code this OP note. Please help!

  1. #1
    Default Unsure how to code this OP note. Please help!
    Medical Coding Books
    Doc performed an umbilical hernia repair with mesh then used laparoscopy to fix the mesh that had buckled. Do I just use the open code--49585? Below is OP note.

    Curvilinear incision along the superior border of umbilucs was made totaling appx. 2.5 cm. Electrocautery was carried down to the subq tissues. A large hernia sac was appreciated and dissection free from the subq layers of the umbilucus. We isolated the hernia sac down to its stalk at the fascial level and dissected it free with electrocautery. The hernia was then entered, and using manual guidance to protect the abdominal contents from injury, the hernia sac was amputated circumferentially at the base.

    We selected a large Ventralex mesh and placed it into the abd. Both tails were sutured cephalad and caudad in a U stitch fashion. We then closed the fascia over the top of mesh with 3 Ethibond sutures.

    We made a 5 mm incision in the LLQ and placed a 5 mm trocar into this sinus and insufflated the abdomen. Upon inspection, the right lateral portion of the mesh did have buckling so we placed and addtional LUQ 5 mm port under direct visualization. Using the Pro-tracker device, we tacked the mesh in the north, sout, east, and west positions. This maneuver corrected all buckling. Pneumoperitoneum was released.

    Thanks in advance for your help!

  2. #2
    I would just bill the open code 49585.

  3. Default
    I would bill the open code but use a modifier 22 to reflect the additional work/time it involved.

  4. #4
    Thanks for responding. I initially thought about the open with 22 modifier, but always seem to doubt myself.

Similar Threads

  1. Dx code throughout note
    By Tonyj in forum E/M
    Replies: 9
    Last Post: 11-13-2014, 12:18 PM
  2. op note - how would u code this?
    By jbrown in forum Cardiovascular Thoracic
    Replies: 0
    Last Post: 10-15-2014, 02:21 PM
  3. ICD-9 code for 'unsure LMP'
    By yt in forum OB/GYN
    Replies: 7
    Last Post: 08-08-2014, 01:00 PM
  4. Unsure of what dx code to use... please help.
    By in forum Diagnosis Coding
    Replies: 2
    Last Post: 11-01-2010, 05:50 PM
  5. Very unsure as to how to code this one. Please help!
    By coder25 in forum General Surgery
    Replies: 1
    Last Post: 02-05-2010, 02:43 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.