What's a coder to do? We've spoken to the surgeon to try to get a better picture, but he claims this is what he did - excised the portion damaged by the previous attempt.
PREOPERATIVE DIAGNOSIS
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.
POSTOPERATIVE DIAGNOSIS:
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.
OPERATIVE PROCEDURE
Exploratory laparotomy with partial gastrectomy with placement of a 20-French gastrostomy tube.
OPERATIVE FINDINGS
The patient had an attempted gastrostomy tube placement by the interventional radiologist At the time of this surgery, there was some moderate amount of clot in the belly and there was a full-thickness hole in the stomach along the greater curvature site of the antrum. This was probably about 5 mm in diameter.
DESCRIPTION OF PROCEDURE
Under general anesthesia, the patient was prepped and sterilely draped Upper abdominal midline incision was made, fascia was divided, peritoneal cavity entered. The stomach was identified and then delivered into the wound. The defect in the stomach was readily apparent We took LigaSure and divided omentum from the greater curvature so we could have greater access to the gastric wall. We then did a partial gastrectomy, we grasped the greater curvature of the stomach with a Babcock clamp; and then using a TA-60 stapler, we came across the stomach and excised a portion of the stomach measuring probably about 5 x 2 cm in length and diameter. We then chose a 20-French gastrostomy tube which we placed in the anterior wall of the stomach close to the greater curvature after placing a 3-0 silk pursestring suture. The seromuscular layer of the stomach was further inverted around the tube with additional 3-0 silk sutures. The stomach itself was tacked up to the anterior abdominal wall with 3-0 silk. The tube flushed well. The midline fascia was then reapproximated with running 0 loop PDS. Skin was closed with skin staples. The patient tolerated the procedure well, left the operating room in good condition.
We were initially led to 43631-52, 43632-52, and a stronger consideration of 43610-52. Feel like we're taking the same road every time we look at this report and left w/the feeling that we're not getting to the right place. Any thoughts would be greatly appreciated to get through this bit of quicksand. Thanks!
PREOPERATIVE DIAGNOSIS
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.
POSTOPERATIVE DIAGNOSIS:
Gastric perforation status post attempted placement of a percutaneous gastrostomy tube.
OPERATIVE PROCEDURE
Exploratory laparotomy with partial gastrectomy with placement of a 20-French gastrostomy tube.
OPERATIVE FINDINGS
The patient had an attempted gastrostomy tube placement by the interventional radiologist At the time of this surgery, there was some moderate amount of clot in the belly and there was a full-thickness hole in the stomach along the greater curvature site of the antrum. This was probably about 5 mm in diameter.
DESCRIPTION OF PROCEDURE
Under general anesthesia, the patient was prepped and sterilely draped Upper abdominal midline incision was made, fascia was divided, peritoneal cavity entered. The stomach was identified and then delivered into the wound. The defect in the stomach was readily apparent We took LigaSure and divided omentum from the greater curvature so we could have greater access to the gastric wall. We then did a partial gastrectomy, we grasped the greater curvature of the stomach with a Babcock clamp; and then using a TA-60 stapler, we came across the stomach and excised a portion of the stomach measuring probably about 5 x 2 cm in length and diameter. We then chose a 20-French gastrostomy tube which we placed in the anterior wall of the stomach close to the greater curvature after placing a 3-0 silk pursestring suture. The seromuscular layer of the stomach was further inverted around the tube with additional 3-0 silk sutures. The stomach itself was tacked up to the anterior abdominal wall with 3-0 silk. The tube flushed well. The midline fascia was then reapproximated with running 0 loop PDS. Skin was closed with skin staples. The patient tolerated the procedure well, left the operating room in good condition.
We were initially led to 43631-52, 43632-52, and a stronger consideration of 43610-52. Feel like we're taking the same road every time we look at this report and left w/the feeling that we're not getting to the right place. Any thoughts would be greatly appreciated to get through this bit of quicksand. Thanks!