UCR 111: How to code, when surgery includes open and laparoscopic; Unspecified diagnoses denial recap
September 2, 2022
Mark, Ray, and Scott discuss what you should do when you have a surgery that includes both open and laparoscopic approaches. Also, Mark recaps the Monthly Webinar "How to avoid unspecified diagnosis denials".
Open and laparoscopic approach example:
So, I am needing some guidance. My provider has done a Retroperitoneal abscess drainage (open) 49060. However, he also removes calculi that was found in the abscess with a nephroscope. I am not finding a definitive CPT that explains this removal but, I am unsure if it would meet criteria for an unlisted laparoscopic CPT.
Any advice would be greatly appreciated.
"After the procedure and its indications were reviewed with the patient, including a review of risks including, not limited to the risk of bleeding, infection, worsening infection, potential need for additional procedures. She signed a consent in the emergency department and was then brought back to the operating room, she had just completed a dose of antibiotics in the emergency room. Once general anesthesia was induced patient was placed into flank position with the left side up. Axillary roll was placed and all pressure points were padded. Patient was then flexed over the break of the table to create space between the 12th rib and the iliac crest.
The abdomen was then prepped and draped in the normal sterile fashion. Just inferior to the tip of the 12th rib a 4 cm incision was made and carried down through subcutaneous tissue with immediate return of purulent debris from the posterior flank. With blunt dissection the track through the posterior abdominal wall was entered and approximately 300 cc of fetid milky brownish fluid was aspirated swab and fluid were sent for culture.
The wound was then copiously irrigated out with about 2 L of saline and blunt dissection in the abscess cavity/retroperitoneum.
12 mm balloon Hassan port was then placed and retroperitoneum was insufflated to 8 mmHg. Laparoscope was advanced into the abscess cavity and several stone fragments were identified.
Using the offset nephroscope several stones were able to be extracted. A white string was identified in the retroperitoneum/abscess cavity, this appeared to be adherent both inferiorly and superiorly, along the medial aspect of the abscess cavity. With gentle traction the inferior aspect gave way, however with traction superiorly the string was densely adhered, but was felt to be up near the renal hilum, though orientation was difficult as no reliable landmarks other than the psoas were readily identifiable.
Decision was made not to apply too much traction and cut the string short. A 5 mm trocar was placed posterior and superior to the current port to allow for placement of a titanium clip to better identify the location of the suture on future scan. String was clipped and then cut and handed off the field.
Several more stone fragments were identified and extracted. In total 18 stone fragments were extracted. The site was inspected repeatedly and probed with the sucker tip, and no stone was identified. Another 2 L or so of irrigation was run through the suction irrigator to flush out the site.
19 French JP drain was then passed through the 5 mm trocar and into the abscess cavity. A second 19 French drain was passed through the initial entry site and out through the skin posteriorly. Both were secured with 3-0 nylon suture. Half inch Penrose was then placed through the incision, lumbodorsal fascia was reapproximated loosely with a 0 Vicryl suture. Skin was then closed loosely with 2 surgical staples.
Site was anesthetized with quarter percent Marcaine."
Link to Monthly Webinar: "How to avoid unspecified diagnosis denials"
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