Can anyone please help in selecting the CPT codes most appropriate to this surgical OP note??
64 year old had a screening colonoscopy in the GI OP clinic - difficulty navigating the sigmoid colon - doc felt he perforated the colon.
Patient was admitted with marked distention. General given via endotracheal tube foley cath placed to decompress the bladder and an orogastric tube placed to decompress the stomach. 5 mm incision made in the umbilicus, a veress needle was placed into the abdominal wall and insufflated with carbon dioxide to a pressure of 15mmHg. Needle was removed and a 5mm trocar was placed into the abdomen. A 5mm 30 degree laparoscope was used to examine the abdomen. There was noted to be a significant amount of air within the wall of the sigmoid colon, extending distally down toward the rectum. A second 5mm port was placed in the left upper quadrant under direct visualization with the laparoscope, and a third 5mm trocar was placed in the right lower quadrant. A 10mm trocar was placed in the lower midline. The sigmoid was carefully examined and there was noted to be an area of perforation. One of the appendix epiploicae was carefully disected away from the wall of the colon using the hook electrocautery. Once this was done the physician could clearly visualize the transmural defect in the wall of the sigmoid colon. The perforation was closed with a series of #2-0 Vicryl sutures placed in interrupted fashion. Once this was done, Tisseel tissue glue was injected laparoscopically in order to cover the repair, after this some adjacent pericolonic fat was tacked over the repair as well. Another physician performed flexible sigmoidoscopy and while occluding the colon proximal to the repair, the colon and rectum were insufflated gently with air in order to test the repair for a leak. This was done under irrigation in to check for a leak. No bubbles noted from the area of the repair. The sigmoidoscope was removed and the air was released from the colon. The abdomen was then copiously irrigated with 2 liters of warm saline. The area of repair in the sigmoid colon was again examined, and it appeared to be intact. All trocar's removed, sites sutured, patient to recovery in stable condition. Patient handled procedure well and all instruments, sponges and needle inventory counts were noted and correct.
Sorry for the long post but this one has be a little baffled....any guidance would be a blessing!! Thanks
Thank you all for your responses - sometimes your brain gets so gray that you can't make a decision anymore!!
Many thanks!!