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Op-Report

  1. #1
    Location
    Long Island/New York
    Posts
    1,271
    Default Op-Report
    Medical Coding Books
    I have this op-report with 45395, 45300 and 38571. I could use some opinions on this please:

    5mm ports were placed in right and left lower quadrant. This would aide in the laparoscopic mobilization of the entire sigmoid colon and rectum. The sigmoid colon was mobilized lateral to medial mobilizing the white line of Toldt. The sigmoid colon was transected using a laproscopic stapling device thru right lower quandrant port. Mesenteric dissection proceeded ina total mesorectal excision fashion mobilizing the rectum from the sacral promontory. The dissection proceeded all the way down to the pelvic floor muscles. We then proceeded with the perineal dissection...the entire sigmoid, rectum, anus tumor musculature were all removed. Transabdominally the decending colon was mobilized and brought up the descending colon as a colostomy in the LLQ area. During the laparoscopic dissection, an extensive lymph node dissection of both iliac and internal hypogastric lymph node packages were performed...

    Thanks..Any input is appreciated. This is all new to me..

  2. #2
    Default
    Sounds correct to me. I guess you have left out the documentation relating to 45300 but I agree with your code selection

  3. #3
    Location
    Long Island/New York
    Posts
    1,271
    Default
    Quote Originally Posted by colorectal surgeon View Post
    Sounds correct to me. I guess you have left out the documentation relating to 45300 but I agree with your code selection
    Yes I did...I'm just surprised that a daignostic test like 45300 would be included in a procedure. When we do other specialties (i.e. ortho) we see any type of diagnostic test as included with another procedure.

    Thanks.

  4. #4
    Default
    You may be right about that. Seems that I have heard in the past that if you're doing a procedure (rigid sigmoidoscopy) to check you work (the anastomosis) you can't charge for that but I'm not sure.

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