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Need CPT help for OP note

  1. #1
    Default Need CPT help for OP note
    Medical Coding Books
    DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the operating table. After satisfactory induction of general endotracheal anesthesia the patient was appropriately positioned in the lithotomy position. Foley catheter was inserted using sterile technique. With the patient in the lithotomy position, the perineum and abdomen was prepped and draped in the usual fashion. After an appropriate time-out a midline incision was made carried through the abdominal wall to the peritoneal cavity which was entered and explored. There were no adhesions to the anterior abdominal wall from the previous lower abdominal incision and exploration was then carried out. A small nodule which was rather firm was noted in the subperitoneal position underneath the right rectus muscle. This was taken out at the end of the procedure. This did not appear to be a metastatic deposit. The liver was cleaned of any metastatic disease. The gallbladder was palpated and no stones were noted. The patient had had a previous appendectomy. Attention was directed first to the pelvis where some residual filmy adhesions to the sigmoid colon were taken down. This then allowed complete palpation from the rectum and sigmoid from the peritoneal reflection up to the sigmoid descending colon junction. Careful palpation failed to reveal any mass or induration which would be consistent with a tumor at 50 cm. At this point I elected to take down the splenic flexure. The lateral peritoneal reflection of the descending colon was incised and carried down onto the pelvis where blunt dissection was used to mobilize the mesocolon and mesosigmoid. Dissection was then carried again digitally up onto the hepatic flexure. This allowed mobilization of the splenocolic ligament which was then taken down using an Endo-GIA stapling device. This was done with a vascular load and numerous firings were obtained until the hepatic flexure was mobilized immediately. Digital and limited sharp dissection was used to mobilize the flexure and its mesentery medially. The omentum was then incised. The omentum was densely adherent to the distal portion of the transverse colon. This was taken down using Kelly clamps and the gastroomental dissection was carried out as well. Once this was completed and the splenic flexure was completely mobilized the tumor was then readily palpated. It seemed to be right at the apex of the splenic flexure of the colon. It was very flat and sessile and could only be palpated by the induration of the edges. Once this was completed a suitable sided distal transaction was identified. A regular GIA with a 3.5 load was used to divide the colon after a small fenestration was made in the mesocolon. This was right around the mid descending colon. Once this was completed, a site of proximal transaction just beyond the middle colic artery was chosen and was transected with a GIA stapling device as well. The mesocolon taken to the splenic flexure was then taken down and divided with Kelly clamps, 2-0 silk ties and 2-0 silk ligatures were used to control these vessels. With this accomplished, packs were placed in the left upper quadrant, along the left gutter. These were left in place and gradually hemostasis was obtained using clips and where appropriate electrocautery. Attention was directed to the left subdiaphragmatic area. The spleen was palpated and it was found to be intact although there had been some oozing of bright red blood up in this location. Most likely this was related to gravitational pull of the intraperitoneal blood. Once these clots were removed a pack was placed up on top of the spleen. It was then pulled out and no active bleeding was noted following this. I could not completely visualize the spleen and nor did I intend to, but the spleen both felt intact and there was no further bleeding that I could appreciate. Satisfied that hemostasis was present within the abdomen and the spleen was intact, I then performed a side-to-side relative end-to-end anastomosis using a GIA stapler. The colocolostomy was then closed transversely after the anastomosis was internally inspected and no bleeding was noted. A TA-60 3.5 load was placed transversely across the colocolostomy and fired. The excess bowel was then removed from the staple. A very large patulous anastomosis was thus achieved. Good serosal apposition was noted around the circumference. Two Dacron sutures of 3-0 silk were then placed beyond the apex of the staple line. Small bleeding points within the staple closure of the colocolostomy were closed with figure-of-eight 3-0 silk sutures. With hemostasis of the anastomosis achieved, the packs were removed from the left gutter and from the left upper quadrant, and once again minimal bleeding was noted. Therefore, the anastomosis and the colon were returned to the abdomen in the right upper quadrant. It laid nicely. The small bowel which had been eviscerated had been returned to the abdomen. Brisk irrigation of antibiotic solution was carried out. The wound was then closed using 0 looped Maxon suture in a continuous fashion. Brisk irrigation was carried out in the subcutaneous tissue and skin clips were then applied. The patient tolerated this procedure well. She was allowed to transfer to the recovery area in satisfactory condition.

    A right subclavian line was inserted without difficulty. Subsequent chest x-ray showed the line to be in good position with no pneumothorax.

    Codes? Thanks...

  2. #2
    49203(with more documentation on the nodule taken out)


  3. #3
    Thanks, I wasn't sure about 49203.

  4. #4
    what about 36556 as well for the central line?

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