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Code This!

Scenario Week of October 25, 2012:
View Current Scenario

Assign the appropriate ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes.

Chief Complaint: RUQ pain, nausea, gas

Scenario: A 45-year-old patient presents for laparoscopic cholecystectomy. Outpatient ultrasound is positive for multiple cholelithiasis

Procedure: Laparoscopic cholecystectomy converted to open procedure, suture repair of intraoperative laceration of abdominal aorta

In the operating suite, the patient was prepped, draped, and positioned. Anesthesia was maintained with fentanyl and isoflurane in oxygen/air. Trocars were inserted through small abdominal incisions. Pneumoperitoneum was induced by insufflation of the abdomen. The patient was repositioned at 30° with a head-up tilt. Approximately thirty minutes post trocar insertion, during the gall bladder dissection, arterial hypertension rapidly decreased (from 28 to 18 mm Hg). The patient developed bradycardia. The procedure was immediately converted to an open abdominal approach. Pneumoperitoneum was released, instruments withdrawn, and ports removed. The abdomen was opened via a subcostal incision in the right upper quadrant. The skin and fascia were dissected down to the abdominal cavity and retractors placed. Abdominal exploration identified intraperitoneal bleeding from a tiny rent in the infrarenal abdominal aorta, possibly during trocar insertion. The aorta was isolated and clamped. The approx. 1 mm rent was immediately sutured and hemostasis was achieved.

Transection of the gallbladder was resumed at the level of the cystic duct using GIA stapler. The stump was reinforced with 2-0 Vicryl suture. The gallbladder was filled with numerous 3-5 mm stones. The specimen was removed and the right upper quadrant was irrigated extensively. No stones were identified inside the peritoneal cavity. The aorta was again checked for hemostasis. No bleeding or oozing was identified. A JP drain was then placed in the right upper quadrant area close to the cystic duct and stump. The abdominal wound was then closed in layers. Dry sterile dressing was then applied. The patient was extubated in the operating room and was taken to the recovery room in stable condition.

Code This! Assign the correct ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes.

ICD-9-CM Diagnosis Codes
574.20 Calculus of gallbladder without mention of cholecystitis
998.2 Accidental puncture or laceration during a procedure
902.0 Injury to blood vessels of abdomen and pelvis, abdominal aorta
E870.0 Accidental cut, puncture, perforation or hemorrhage during medical care, surgical operation

ICD-9-CM Procedure Codes
51.22 Cholecystectomy
39.31 Suture of artery
V64.41 Laparoscopic surgical procedure converted to open procedure

ICD-9-CM Coding Rationale
Assign code 998.2 Accidental puncture or laceration during a procedure, to describe the surgical complication. Code 902.0 Injury to blood vessels of abdomen and pelvis, abdominal aorta, is also assigned to specify the site of the laceration (rent) because this code describes the nature of the complication. Code V64.41 is assigned as an additional diagnosis to report the conversion of the planned laparoscopic procedure to an open procedure. Code 39.31 represents the repair of the intraoperative laceration of the aorta.

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