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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.
____________
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.
Preoperative Diagnosis
LARGE UMBILICAL HERNIA
Postoperative Diagnosis
SAME
Procedure Performed
UMBILICAL HERNIORRHAPHY AND UMBILICOPLASTY
Type of Anesthesia
General endotracheal, transabdominal peritoneal block
Indications
The patient is a ___year-old woman who was being followed for over a year with an umbilical hernia that was increasing in size and becoming more symptomatic. Options for repair have been discussed and she agreed with open repair and umbilicoplasty, since it had been distorted. The possible risks, benefits and complications of umbilical herniorrhaphy and umbilicoplasty was discussed. She finally agreed proceed with surgery.
Findings
Large umbilical hernia with redundant hernia sac and redundant skin
actual defect ~3.4cm
Unanticipated Events/Complications
None apparent
Specimen(s) HERNIA SAC
Technique/Description of Procedure
Patient was brought to the or on _________ and placed on table in supine position. After adequate general anesthesia, the patient was prepped and draped in a sterile fashion. An allis clamp was used to lift up the umbilicus and a semicircular incision was made in the infraumbilical space. The incision was carried down the subcutaneous tissue and scarpa’s fascia was divided. A tonsil clamp was used to dissect widely around the umbilicus until the hernia sac was isolated.care was taken to carefully dissect through the layers of the hernia sac. The hernia sac was noted to have omentum as contents that were reduced back into the peritoneal cavity after electro bovie cautery was used to control oozing. The large hernia sac was grasped and resected with the electrocautery. The edges of the fascia were cleaned off and grasped with allis clamps. The fascia was approximated with 0 ethibond stitches in a figure of 8 fashion. They were tacked with hemostats until all were placed. Inspection was undertaken to ensure no intra-abdominal contents were in the stitches. The stitches were then tied individually. Hemostats were used to retract up the stitches to checked the space between the suture repair. Another 0 ethibond stitch was placed between the stitches that were greater than a 1/2 centimeters apart.
Irrigation was undertaken. 0.5% marcaine was injected to the area along the stitches and fascia, then the subcutaneous tissue and the umbilical flap. The umbilical flap was secured back down to the fascia with 0 ethibond stitch to recreate the umbilicus. Then interrupted 3 0 vicryl stitches were used to approximate the scarpa’s fascia and subcutaneous tissue. The excess skin was then measured out and excised. The skin was approximated with 4 o monocryl running subcuticular stitch. Mastisol, steri-strips and a cotton ball in the umbilicus, telfa and tegaderm were placed for dressing. The hypodermic needle was used to create a vacuum seal in the dressing. The patient tolerated the procedure well. The patient was extubated and brought to recovery room in stable condition.
Thanks, 😀
Jodi Dibble, COC, CPC
There is a CCI edit between the codes 49561 and 15830.
Would the panniculectomy be considered a separate service since in this instance the patient had a large hernia?
Thanks,
BB
Thanks…
Please see below scrubbed highlights from my operative note.
Does the aborted procedure bundle into the completed procedure? I would usually think so but both hernia procedures have distinctly separate CPT codes as well as DX codes.
Any thoughts are appreciated…thanks in advance.
POSTOPERATIVE DIAGNOSES:
1. Left inguinal hernia.
2. Recurrent right inguinal hernia.
PROCEDURE:
1. Laparoscopic left inguinal hernia repair.
2. Attempted right inguinal hernia repair.
LEFT – Sequenced as primary procedure
49560-LT
C1781 [mesh]
K40.90 New Inguinal hernia
D17.6 Cord Lipoma
— was dissected laterally
— dissected out a large cord lipoma [no pathology]
— cleared off the internal ring on the left side.
— placing a left-sided laparoscopic ProGrip mesh
RIGHT -Sequenced as secondary procedure due to reduction of services [NCCI edits]
49651-53-51-RT
K40.91 Recurrent Inguinal Hernia
K91.61 Intraoperative Hemorrhage during digestive procedure
K66.0 Adhesions
Z53.8 Procedure not carried out
— placed our balloon dissector
— the right side was not dissected very well
— peritoneum was densely adherent to the abdominal wall
— there was some bleeding from numerous small vessels
— tried to take down the connective tissue from the right inferior epigastric.
–did incur some bleeding
had to be controlled by ligating the inferior epigastric vein between clips.
–then could not visualize the hernia defect at this point
— Right inguinal hernia repair was aborted
OPERATION PERFORMED:
1. Diagnostic laparoscopy.
2. Reduction of internal hernia.
3. Closure of peritoneum.
PREOPERATIVE DIAGNOSIS: Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Small bowel obstruction.
DESCRIPTION OF PROCEDURE: We used the same infraumbilical 5 mm incision and
reopened the incision. Due to his recent surgery, we used the same opening to
enter a 5 mm port with a blunt tip. Once the port was entered, insufflation was
obtained. Two additional ports were placed initially 5 mm on the left and right
side of the umbilical port. On initial evaluation, the patient had a loop of
small bowel going into the peritoneum, which appeared to be herniated through
the peritoneal defect, even though it appeared that the peritoneum had split
open. Using 2 blunt graspers, we were able to reduce the small bowel out of
this defect and evaluate the small bowel which appeared viable and pink. The
small defect which measured roughly 1 cm was closed with intracorporeal suture
using 3-0 Vicryl suture, using a figure-of-eight suture. In order to do that,
we did have to insert a 12 mm port on the left side. Next, we evaluated for any
other defect and we did not find any other issues, so at this time desufflation
was achieved and the fascia of the 12 mm was closed with interrupted
figure-of-eight Vicryl suture. The skin of all the incision was closed with 4-0
suture. Local was injected. Sterile dressings and Dermabond were placed over
the skin incisions. All sponge, needle and instrument counts were correct at
the end of the procedure.