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Check your diagnosis coding for this patient encounter. PREOPERATIVE/POSTOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia. PROCEDURE PERFORMED: Laparoscopic right inguinal herniorrhaphy with mesh. BRIEF HISTORY: This patient is a 66-year-old African American male who presented to Dr. Y’s office with recurrent right inguinal hernia for the second time, requesting hernia repair. History of attempt at open […]
The post Recurrent Inguinal Hernia appeared first on AAPC Knowledge Center.
Differentiate hernia repairs and surgical approaches for improved medical coding. A hernia occurs when an internal part of the body pushes or squeezes through a weak spot in a surrounding muscle or connective tissue (fascia). Although most hernias are harmless and pain-free, some may be painful and dangerous. Surgery is the only cure for a […]
The post Simplify Hernia Repair Coding appeared first on AAPC Knowledge Center.
49585 -22 or
49585/unlisted code (if so, what amount) OR
49585 by itself
PREOPERATIVE DIAGNOSIS: Pre-Op Diagnosis Codes:
* Ventral hernia with obstruction [K43.6]
POSTOPERATIVE DIAGNOSIS: Post-Op Diagnosis Codes:
* Ventral hernia with obstruction [K43.6]
*
PROCEDURE/SURGERY: Repair of umbilical hernia and small periumbilical diastasis
*
*
ANESTHESIOLOGIST: Anesthesiologist: xxxxxx
ANESTHESIA TYPE: General
*
ESTIMATED BLOOD LOSS: minimal
*
COMPLICATIONS: none
*
FINDINGS: small diastasis andumbilical hernia
*
SPECIMENS: none
*
INDICATIONS FOR SURGERY:bulge and pain
*
SUMMARY OF PROCEDURE:
Patient was placed in the operating table in the supine position. General anesthesia was administered. The abdomen was prepped and draped in the usual fashion. A periumbilical midline incision was made and the hernia was identified. The hernia sac was clearly dissected. The hernia sac was reduced inside and the fascia was closed over with a running ethibond suture. After closure of the fascia, the small diastasis was closed with interrupted ethibond. the subcutaneous tissue was dissected one by four mesh was fashioned and placed over the fascial closure and anchored circumferentially to the fascia with interrupted vicryl. The area was then irrigated with antibiotic solution. . After obtaing hemostasis , the subcutaneous tissue was closed with 3- 0 vucryl and subcuticular monocryl for skin Sterile dressings were applied. Firm pressure dressings placed. Final sponge , needle and instrument count was correct.
PREOPERATIVE DIAGNOSIS: Pre-Op Diagnosis Codes:
* Ventral hernia with obstruction [K43.6]
POSTOPERATIVE DIAGNOSIS: Post-Op Diagnosis Codes:
* Ventral hernia with obstruction [K43.6]
*
PROCEDURE/SURGERY: Repair of umbilical hernia and small periumbilical diastasis
*
ANESTHESIOLOGIST: Anesthesiologist: xxxxxx
ANESTHESIA TYPE: General
*
ESTIMATED BLOOD LOSS: minimal
*
COMPLICATIONS: none
*
FINDINGS: small diastasis andumbilical hernia
*
SPECIMENS: none
*
INDICATIONS FOR SURGERY:bulge and pain
*
SUMMARY OF PROCEDURE:
Patient was placed in the operating table in the supine position. General anesthesia was administered. The abdomen was prepped and draped in the usual fashion. A periumbilical midline incision was made and the hernia was identified. The hernia sac was clearly dissected. The hernia sac was reduced inside and the fascia was closed over with a running ethibond suture. After closure of the fascia, the small diastasis was closed with interrupted ethibond. the subcutaneous tissue was dissected one by four mesh was fashioned and placed over the fascial closure and anchored circumferentially to the fascia with interrupted vicryl. The area was then irrigated with antibiotic solution. . After obtaing hemostasis , the subcutaneous tissue was closed with 3- 0 vucryl and subcuticular monocryl for skin Sterile dressings were applied. Firm pressure dressings placed. Final sponge , needle and instrument count was correct.
After being placed supine on the operating room table, anesthesia was induced and the patient intubated
without difficulty. The area of the entire abdominal wall was then prepped and draped in a sterile fashion and
a final time out then performed confirming right site and right patient.
A ten blade scalpel was used to make an upper midline celiotomy incision. Electrocautery was used for
hemostasis and to continue the dissection through all subcutaneous layers until the anterior fascia of the
rectus musculature could be identified. Electrocautery dissection was used to dissect subcutaneous tissues off
of the anterior abdominal wall fascia along the entire length of the midline incision until the rectus muscle
separation was completely exposed. The midline of the diastasis recti was then opened exposing the
abdominal cavity completely. At this point, a moderate sized diastasis recti with a small supra-umbilical
ventral hernia could be identified.
Using electrocautery, excess subcutaneous tissues and midline fascia was excised and discarded into order to
restore the normal boundaries of the medial aspect of the rectus musculature bilaterally. All layers of the
anterior abdominal wall were then re-approximated in the midline using running looped 0 PDS sutures. This
included completely re-approximating the inferior hernia defect primarily. The entire surgical field was then
copiously irrigated using diluted Betadine solution. The midline abdominal wall soft tissues were then reapproximated
in the midline in a layered and centrally mattressed fashion using interrupted 3-0 Vicryl
sutures. The midline incision was then closed using skin staples.
The primary hernia repair and plication of the diastasis recti complete, attention was now turned to the
laparoscopic portion of the hernia repairs with mesh implantation. After placing a left upper quadrant
abdominal port under direct visualization, pneumoperitoneum was achieved to a pressure of 15 mm Hg.
Three additional trocars were placed in the other anterior abdominal wall quadrants sequentially using a 15
blade scalpel to make separate transverse incisions and the laparoscope for direct visualization. Harmonic
scalpel dissection was then used to separate the Falciform ligament from the superior aspect of the primarily
re-approximated abdominal wall defect as well as adhesive disease inferior to the umbilicus to allow for a
smooth posterior abdominal wall surface for mesh attachment. Once cleared, the defect was measured and a
20 x 7 cm piece of Proceed composite mesh fashioned for fixation. Two corner 2-0 PDS sutures were placed
along the textured surface of this graft which was then irrigated using diluted Betadine solution, rolled,
passed into the abdominal cavity, and unrolled without difficulty. A suture passer was then used to
exteriorize each fixation suture through a small stab incision made in the anterior abdominal wall using an 11
blade scalpel. These sutures then allowed the mesh to lie smoothly across the midline ventral defects in an
underlay fashion. The patch was further secured in place using a 5 mm SecureStrap device at approximately
1.5 cm intervals circumferentially.
At this point, all ports were removed under direct visualization and pneumoperitoneum released in full. All
remaining skin incisions were then irrigated using diluted Betadine solution and re-approximated using
staples. The port site incisions were cleaned, dried and dressed sterilely using Bacitracin, Telfa gauze, and
Tegaderm. The suture passer incisions were closed using staples and the entire abdominal wall midline then
dressed using Bacitracin and an Aquacel Ag surgical coverlet. Sponge and instrument counts were confirmed
A 2 inch transverse incision was made overlying the incarcerated ventral hernia was located at the supraumbilical position. There was a golf ball sized hernia sac containing preperitoneal fat and omentum. The sac was excised and the incarcerated omentum was suture ligated with 0 silk suture and the excess excised. This left a 2 cm fascial defect. This allowed for placement of a 12 mm Hassan trocar. The abdomen was then insufflated to 15 mmHg pressure and carbon dioxide the 0°, 10 mm camera was then inserted and the abdomen was inspected (see findings). Under direct vision a 5 mm bladed trocar was placed in the subxiphoid position and 2, 5 mm ports were placed in the right upper quadrant. The patient was then positioned reverse Trendelenburg, left lateral tilt.
*
The gallbladder was then retracted in a cephalad manner using 2, 5 mm graspers. Due to the acute edema within the gallbladder, a cholecystostomy was created with a grasping forceps and the gallbladder decompressed of dark green bile. The Maryland dissector was used to create a posterior window behind the cystic duct. The cystic duct junction with the gallbladder was clearly identified. The duct was milked towards the gallbladder junction. The cystic duct was singly clipped distally and plans were made for intraoperative cholangiogram.
*
A stab incision was performed in the right upper quadrant and the taut catheter introducer placed. The 4.5 French taut catheter was primed with full-strength contrast and saline. The cystic duct was partially divided allowing for placement of the taut catheter that was clipped in place. Intraoperative cholangiogram was then performed. There is no biliary ductal dilation. There is no evidence of choledocholithiasis. The contrast emptied quickly into the duodenum. The distal pancreatic duct also visualized consistent with a common ampulla. Following completion of the intraoperative cholangiogram, the taut catheter was removed from the cystic duct that was then doubly clipped proximally and completely divided. The cystic artery was also identified going to the gallbladder. This structure was also clipped proximally and distally and then divided. The gallbladder was then peeled away from the liver bed using electrocautery. Once detached from the liver bed it was withdrawn from the periumbilical port site in a routine manner. The gallbladder was sent to pathology
Excision of meshoma and neurectomy of the Genital branch of the GF nerve. Primary repair of the iatrogenic creation of the fascial defect using a primary suture technique and fascial release.
dx:Left inguinodynia. Cannot exclude recurrent left inguinal hernia. Status post bilateral laparoscopic inguinal hernia repair
thank you
I am in a quandary…any insight will be appreciated.
The provider clearly documents no hernia, no defect, no areas of weakness…but then places mesh anyway?
How can I capture the mesh insertion without hernia repair…am leaning toward 154xx from integumentary system codes but not sure???
POST-OP DX: Right Cord Lipoma
PX: Open Right Inguinal Hernia Repair with Mesh
*inspected the floor of the inguinal canal and identified no defects or areas of weakness
*no hernia sac was identified and the internal ring was well intact
*prior mesh repair of the laparoscopic hernia repair – intact
*identified a cord lipoma distally, and resected that from the spermatic cord.
** then placed a piece of ProGrip mesh and secured to the pubic tubercle
Post Op Note:
informed him that his prior repair was intact and that his bulge was likely from a cord lipoma
Thanks in advance…
PROCEDURE: Open repair of incarcerated right inguinal hernia with mesh (3 x 6 inch polypropylene onlay) incidental appendectomy.
*
SPECIMENS: 1. Incidental appendectomy 2. Hernia sac
*
A right inguinal incision was performed in a standard fashion and carried down to the superior aspect of the scrotum. Subcutaneous tissue was incised through Scarpa’s layer to the external oblique fascia. A large sac was identified communicating with the cantaloupe sized scrotal hernia. The external oblique fascia was incised from the external to the internal ring. Attenuated internal oblique musculature overlying the sac was divided with the electrocautery. The sac was then incised. This allowed for manipulation of the sac contents away from the edges of the sac so that it could be dissected free from the spermatic cord. The spermatic cord structures were identified and protected throughout the case as were the sensory nerves of the inguinal canal. 1/4 inch Penrose drain was placed about the spermatic cord. The enlarged sac was dissected back to the dilated internal ring. At this point the patient was placed in Trendelenburg position and sac contents were reduced. Prior to reduction of the cecum, an elongated normal-appearing appendix was removed by first ligating the mesoappendix and tying off the vessels with interrupted 2-0 silk. The base of this appendix was clamped and the appendix was excised. The base of the appendix was tied off with 0 silk suture and the tip of the base was electrocauterized. Following reduction of the sac contents, it was identified that there was a large internal ring that required support.
*
A 3 x 6 inch polypropylene mesh was then placed within the inguinal canal. It was sutured in place with interrupted 2-0 Vicryl, to the Cooper’s ligament medially and along the reflected edge of the inguinal ligament inferiorly. The mesh was split laterally allowing the cord to lie anterior to the mesh. The mesh was sutured superior medially to the conjoined tendon. The tails were brought together laterally, recreating an internal ring. The tails were tucked under the external oblique fascia.
*
The dead space within the scrotum was inspected. The edges of the peritoneal sac were cauterized. 1/2 inch Penrose drain was placed in the dead space and brought out through the inferior aspect of the scrotum via a stab incision and sutured in place with 3-0 nylon. The drain was left within the scrotum and the soft tissue surrounding the drain, superiorly was closed off from the inguinal canal using a pursestring suture of 2-0 chromic, to prevent communication of the drain with the mesh. Prior to this, the wound and the scrotum were irrigated thoroughly with warm saline and hemostasis was obtained. The closure was with a running 2-0 Polysorb and the external oblique fascia. Scarpa’s layer was closed with interrupted 2-0 chromic. The skin was closed with staples. A sterile gauze dressing was applied and secured with Medipore tape. The wound was infiltrated with 0.25% Marcaine with epinephrine, 30 mL. A scrotal support was placed with gauze. The patient tolerated the procedure well and was taken to the recovery room stable.
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