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code a round help

  1. Unhappy code a round help
    Medical Coding Books
    I don't know why this one should be so hard. I can't seem to find a diagnosis code that fits. Maybe I am in the wrong business. The one procedure code that was accepted is 49204. I believe that the lysis of adhesions would be included in that, but they don't tell you whether you are missing a diagnosis code or a cpt code. I am totally stumped and frustrated.

    OPERATIVE REPORT
    DATE OF OPERATION: March 10, 2010
    PREOPERATIVE DIAGNOSIS: Pelvic mass and adhesions
    POSTOPERATIVE DIAGNOSIS: Pelvic mass and adhesions
    OPERATIVE FINDINGS: A 4 x 6 cm cystic structure present in the posterior cul-de-sac. Multiple small bowel and large bowel adhesions to the anterior peritoneum.
    OPERATION: The patient is carried to the operating room and she is placed in a supine position. After adequate level of anesthesia obtained, prepped and draped in usual manner for vaginal and abdominal surgery in the supine position. _____ opened her by a midline vertical incision through the fascia and bowel was sharply dissected free by him without difficulty Once the bowel was resected off the anterior peritoneal wall, I was able to get into the cul-de-sac area without difficulty and the cystic structure was identified This was away from the ureters, pretty much just right of midline. The area was localized and cyst was elevated and excised without difficulty. Once this was done, there was some bleeding that was present and a couple of 2-0 silks were placed to control hemostasis, as well as utilizing the Bovie. Once hemostasis was noted, Surgical was placed across the surgical site and the area was closed with the anterior fascial layer closed with 0 Maxon in a running fashion. Skin was reapproximated using a 4-0 PDS in a subcuticular fashion. The patient tolerated the procedure without difficulty.
    ESTIMATED BLOOD LOSS: Approximately 20 cc
    PACKS AND DRAINS: Foley catheter. Sponge count was correct x2
    Last edited by cyndiann; 01-13-2012 at 11:01 AM.

  2. #2
    Location
    Greater Orlando
    Posts
    146
    Default HIPPA Reminder
    Please remember scrub notes before posting; remove any and all references to patient's name, physicians' names and other identifying information.

    Please edit this Op Note if the system will still allow you to do so.

    Thanks,
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  3. #3
    Location
    Greater Orlando
    Posts
    146
    Default What codes have you tried?
    What is (are) your Dx code(s)?

    Thanks,
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  4. Default
    That is my problem. I can't find a diagnosis code that fits. I am either missing something, or .....

  5. #5
    Location
    Greater Orlando
    Posts
    146
    Default Dx code(s)
    How about the following?

    789.39 Abdominal or pelvic swelling, mass, or lump
    ...[9 = other specified site] since the location of the posterior cul-de-sac is not identified by 5th digit options 0-7.

    586.0 Peritoneal adhesions
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  6. Unhappy
    I have tried both of those. Does anyone know of a way to get the answers? I would be more than willing to sacrifice my $10.00 and my 1 CEU just to know what they are looking for. I have noticed that quite a few people have the same problems. Is there an avenue to persue?

  7. #7
    Default
    I've had similar issues with the ASC code around. I just kept going back to the op report and trying different codes and eventually find it. They haven't been the codes I would have used so maybe if you think outside the box you'll find it. Sometimes you just have to stop for awhile and go back to it. good luck.
    Anastasia, CPC, CASCC, COBGC

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