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Thread: help coding this report

  1. #1

    Default help coding this report

    AAPC: Back to School
    I have copied part of my op report below and need some help coding this. I've only been coding general surgery for 2 weeks. Px says exp laparscopy, open removal of abdominal wall mass, repair fscial defect with primary closure and a small piece of mesh.

    a port was placed and a scope inserted. no injury upon entering the abdomen.there was a piece of omentum stuck to the anterior abdominal wall. for this reason the port was left in place and pneumoperitoneum was released. an incision was made in the lower midline through which the bovie cautery was used to dissect down to the fascia of the anterior abdominal wall. fascia was opened and the peritoneal space was entered from this incision as well.there was a mass just superficial to the fascia which was dissected om it anterior and lateral surfaces as well as inferior and medial surfaces. it was left in place and the omentum that was stuck up to the abdominal wall was removed. there was no apparent fascial defect and the entirely of the fascia had to be opened to ger to this place. therefore once the omentum was taken off the anterior wall the peritoneum was closed and a second 5 mm trocar was placed between the stitches. gas insufflation was achieved again into the intra-abdominal space and the sppendix was manipulated and there was no appendicitis noted. the trocars were removed. pneumoperitoneum again was released the mass was then removed in its entirety with a small piece of fascia. this left a small fascia defect which could be closed with a 1 x 6 piece of mesh. there was onl a small abdominal wall defect left to be closed after the fascia was closed primarily in the superior and inferior apices. this was done with 2-0 prolene. the defect was closed in it entirety and 2-0 vicryl was used to reapproximate the subcutaneous tissue below the skin.


  2. #2
    Join Date
    Apr 2007
    Johnson City


    I would consider using code 49203-49205 depending on the size of the mass. It sounds like it started laparoscopic and then the surgeon opened the patient, and then tried to finish laparoscopic. When a procedure converts from laparoscopic to open you bill the open code only, use dx V64.41 in addition to the dx for the mass.


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