I wanted to know if anyone can review this op report and give me your thoughts on it. My doctor wants to bill an unlisted code for the hernia repair but I believe CPT codes 49566 and 49568 support the documentation. I think I’m getting thrown off because of where the hernia occurred (thoracoabdominal area). I have attached the op report with all identifying info blocked out as well as pasted the report below.

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PREOPERATIVE DIAGNOSIS:
1. Left thoracoabdominal incisional hernia.
2. Status post latissimus dorsi flap to the left thorax.
3. Status post remote left thoracoabdominal gunshot wound.

POSTOPERATIVE DIAGNOSIS:
1. Left thoracoabdominal incisional hernia.
2. Status post latissimus dorsi flap to the left thorax.
3. Status post remote left thoracoabdominal gunshot wound.

PROCEDURE:
1. Repair of complex left thoracoabdominal incisional hernia,
recurrent, with mesh.
2. Extensive lysis of adhesions.

INDICATIONS FOR PROCEDURE: This patient is a patient who suffered a self-inflicted shotgun wound to the left thoracoabdominal region several years ago. Had a very complicated history but ultimately recovered with a significant symptomatic incisional and wound-related hernia in the left thorax, in the area of the stomach and left chest wall. The patient underwent attempt at repair a year ago, at which time had a latissimus dorsi flap placed for coverage, but the hernia was unable to be successfully repaired due to inability to place a prosthetic mesh.

PROCEDURE:
Patient was brought to the operating room and positioned supine on the operating room table, intubated, and then positioned with the left side up for a left-sided incisional hernia repair in the left thoracoabdominal region, essentially from the nipple to the 12th rib, from the mid clavicle to the anterior axillary line.

Once the patient was properly positioned, all pressure points were protected, the area was prepped with Chlorhexidine solution and sterilely draped, with the additional use of a Biodrape. We began with a curvilinear incision, on the medial aspect of the flap, entering the area of the hernia and at this point we encountered the colon and small bowel. A very tedious lysis of adhesions was then performed. Enterolysis required approximately 2 1/2 hours, in order to mobilize the colon and small bowel, in order to gain a plane for mesh placement. There is no way to repair this hernia without a mesh. The area was clean, and there were no enterotomies or contamination. We chose a Ventralight mesh and cut it to size, approximately 16 cm x 8 cm and we began sewing it into place as an underlay with interrupted 0 Ethibond suture. The mesh lay in good position, was nice and tight. We irrigated with antibiotic solution, and confirmed hemostasis. Ultimately, we closed the wound, bringing the flap back into place, tacking it down and sewing the tissues in layers with Vicryl suture, and skin staples. Patient tolerated the procedure well.