I have posted scrubbed note highlights. I have also added codes next to the listed procedures.
Thank you in advance for any guidance.
Will this also need modifiers for multiple surgeons??
Patient is male.
UROLOGY NOTE:
PREOPERATIVE DIAGNOSIS: Colovesical fistula. N32.1
POSTOPERATIVE DIAGNOSIS: Colovesical fistula.
PROCEDURES PERFORMED:
1. Cystourethroscopy with bilateral ureteral catheter placement (will be removed postoperatively) 52005-50
2. On table cystogram. 51600 (NCCI edits say it cannot be coded with 52005 – no unbundling allowed)
** imaging for cystogram 74430
3. Cystorrhaphy 51865
** with omental interposition. 49905????
GENERAL SURGERY NOTE:
PREOPERATIVE DIAGNOSIS: Enterovesicular fistula. N32.1
POSTOPERATIVE DIAGNOSIS: Enterovesicular fistula.
PROCEDURE:
1. Exploratory laparotomy. BUNDLES
2. Lysis of adhesions. APPEND -22 TO PRIMARY PX
3. Ileocecectomy. 44160
4. Ileocolic anastomosis. BUNDLES TO ILEOCECECTOMY
5. Urachal remnant/ peritoneal flap creation. 49905???
Urologist
— cystoscopy
— performed a cystogram
–Following his cystogram, we replaced the cystoscope and cauterized several small mucosal tears as a result of slightly overfilling his bladder
— placed ureteral catheters,
General surgeon
–They mobilized the bowel and remove the portion of small bowel
adherent to the posterior wall of the bladder.
–They had excellent exposure of the bladder and retracted the bowel cranially so we could fully visualize the fistula.
Urologist
–We mobilized the peritoneum on either side and covered this fistula with interrupted Vicryl sutures.
–We then mobilized the omentum with the base off of the right
gastroepiploic artery for interposition flap.
— we performed another cystogram using methylene blue and noted no extravasation of methylene blue.
** We then turned the rest of the case over to our general surgery colleagues who would later place the omental interposition graft following their bowel resection.
General surgeon
— urachal remnant that had been taken down from the umbilicus at the beginning of the case was then packed over this area of repair as an extra added layer and a omental pedicle flap was created by urology
—
— attention to creating the bowel anastomosis.
— bowel was isolated per our colorectal protocol and a stapled anastomosis was created