Appendectomy
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Anatomy
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Diagnosis/ Condition
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Surgical treatment
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How to lead CPT code
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CPT code selection criteria
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Live chart sample
1.Anatomy
Cecum is the pouch like structure and it is located at beginning of large intestine. Appendix is attached to the cecum at posteromedial wall and 2cm below ileocecal junction. It is vestigial organ as its function is not known.
Appendix is divided into three parts: Base, body, and tip.
Appendix submucosa contains many lymphoid follicles, so also known as abdominal Tonsil.
2.Disease and Condition
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Appendicitis means inflamed appendix
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Ruptured Appendix: if appendicitis does not treat for long time, it causes burst, tear of rupture and can leak content to the abdomen.
3.Surgical treatment
Appendectomy: It is the surgical procedure to removal appendix.
4.How to lead correct CPT Code
In CPT book ,
Excision-Appendix - 44950,44955,44960
Laparoscopy-Appendectomy- 44970
5.Code selection criteria for Appndectomy
The code selection criteria for Appendectomy is based on
1.Approach : Open/ Laparoscopy
2.Other condition such as rupture or perforation of Appendix
Tips 1
Sometime during other procedure of intestine, the appendix is also removed so we will code the add code +44955 for such procedure.
Live Sample Chart 1
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute suppurative appendicitis.
PROCEDURE PERFORMED: Laparoscopic appendectomy.
ANESTHESIA: General endotracheal and Marcaine 0.25% local.
INDICATIONS: This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain. On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. However, the patient with additional history of loose stools for several days prior to event. Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. There was no evidence of colitis on the CAT scan. With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. She agreed to procedure and informed consent was obtained.
GROSS FINDINGS: The appendix itself noted to have a significant inflammation about it. There was no evidence of perforation of the appendix.
PROCEDURE DETAILS: The patient was placed in supine position. After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg. The Veress needle was then removed. A 10 mm trocar was then introduced through this incision into the abdomen. A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. Photo documentation was obtained.
A 5 mm port was then placed in the right upper quadrant. This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. Through this port, the dissector was utilized to create a small window in the mesoappendix. Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure. Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it. The appendix was then removed from the 12 mm port site and taken off the surgical site. The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated. The base of the appendix was reevaluated and noted to be hemostatic. Aspiration of warm saline irrigant then done and noted to be clear.
There was a small adhesion appreciated in the region of the surgical site. This was taken down with blunt dissection without difficulty. There was no evidence of other areas of disease. Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. The instruments were removed from the patient and the port sites were then taken off under direct visualization. The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2. Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.
Answer 44970 Laparoscopy, surgical, appendectomy. The provider removes the appendix via laparoscopic technique.
Live Sample Chart 2
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
PROCEDURE: Laparoscopic appendectomy.
ANESTHESIA: General endotracheal.
INDICATIONS: Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain. History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan. I evaluated the patient in the emergency room and recommended that he undergo the above-named procedure. The procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.
FINDINGS: Acute appendicitis
TECHNIQUE: The patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with Betadine solution and draped in sterile fashion. An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an Allis clamp and two stay sutures of 2-0 Vicryl were placed on either side of the midline.
The fascia was tented and incised and the peritoneum entered by blunt finger dissection. A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained. Patient was placed in the Trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed. The appendix was easily visualized, grasped with a Babcock's. A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum. The mesoappendix was divided using the Endo GIA with vascular staples. The appendix was placed within an Endo bag and delivered from the abdominal cavity.
The intra-abdominal cavity was irrigated. Hemostasis was assured within the mesentery and at the base of the cecum. All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution. The infraumbilical defect was closed with a figure-of-eight 0 Vicryl suture. The remaining wounds were irrigated and then everything was closed subcuticular with 4-0 Vicryl suture and Steri-Strips. Patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.
Answer 44970 Laparoscopy, surgical, appendectomy. The provider removes the appendix via laparoscopic technique.
Live Sample Chart 3
PREOPERATIVE DIAGNOSIS: Appendicitis.
POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated.
PROCEDURE PERFORMED: Appendectomy.
ANESTHESIA: General endotracheal.
PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.
A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia. The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp. The internal oblique fascia was similarly incised and its muscular fibers were similarly spread. The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident. Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.
The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound. After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties. The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix. The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp. The stump of the appendix was cauterized and the cecum was returned to the abdomen.
The peritoneum was irrigated with warm sterile saline. The mesoappendix and cecum were examined for hemostasis which was present. The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was placed on the wound. All surgical counts were reported as correct.
Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition
Answer 44950 Appendectomy The provider removes an inflamed appendix, a saclike structure situated in the right lower quadrant of the abdomen at the junction of the large and small intestines.
Answer 20560 : Needle insertion(s) without injection(s); 1 or 2 muscle(s). The provider, typically a physical therapist, inserts a needle, without medication, into a trigger point of 1 or 2 muscles to help relieve pain.
Live Sample Chart 6
A 48-year-old Male presents with neck pain, muscle-tension headaches, and diffuse right-shoulder myofascial pain.The physician or other qualified health care professional palpates and locates the trigger points to be needled. Secure the first muscle between the fingers of the nonneedling hand. Insert sterile, single-use, solid-filament needles, varying from 32 to 38 gauge and 25 to 100 mm in length, at various depths and angles to achieve the desired result of releasing tight tissue, improving microcirculation, and removing neuronoxious chemicals. Make interactive reassessments throughout the procedure, noting needle fibrillation, local twitch response, and/or reproduction of symptoms, including but not limited to achiness, burning, and electricity. Repeat this process for each additional muscle to be treated. Withdraw the needles and apply pressure (hemostasis) directly to the skin over the needle-insertion site.