For hospital outpatient reporting, what is the correct code assignment?
Operative Report
Preoperative Diagnosis: Cholecystitis with cholelithiasis
Postoperative Diagnosis: Same
Operative Procedure: Laparoscopic cholecystectomy
Indications: A 77-year-old woman experiences upper abdominal pain and has been
diagnosed with cholelithiasis. The risks and benefits of the procedure have been
explained in detail.
Technique: With the patient under general anesthesia, the abdomen was prepped and
draped in the usual fashion. A small infraumbilical skin incision was made, carried down
through the adipose tissue. The fascia was opened in the midline, and the peritoneal
cavity under direct vision using open laparoscopic technique. There was adequate
insufflation of CO2.
A 10-mm trocar was introduced into the upper abdomen to the right of the midline, two
55-mm trocars in the right upper quadrant area under directed camera vision.
Examination noted that there were multiple adhesions in the gallbladder area. At this
point, I was notified that the patient’s blood pressure was 150/80 and then dropped to
90/55. The blood pressure was stabilized but the decision was to abort the procedure at
this time. All trocars were taken out under direct camera vision. The CO2 was desufflated.
Infraumbilical incision was closed using 4-0 Vicryl subcuticular sutures, and Steri-Strips.
She will be closely monitored and I will contact her primary care physician to discuss her
condition.
a. 47562–52
b. 47562–53
c. 47562–73
d. 47562–74
d. 47562–74
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