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Posted By Maria on 12-03-2019, 12:16:11 in Ob-Gyn
Hey Melanie,

Would you please help me with a CPT for this procedure?

Thanks, Maria

SUGERY DATE:11/27/2019 DOB:10/19/1994
 
PREOPERATIVE DIAGNOSIS:
Left broad ligament hematoma
 
POSTOPERATIVE DIAGNOSIS:
Same
 
OPERATION:
1. Exploratory of left retroperitoneal space
2. Evacuation of hematoma
3. Ligation of bleeding vessels
 
 
ANESTHESIA:
Spinal
 
ESTIMATED BLOOD LOSS:
100 mL
 
INDICATIONS:
Called in for expanding left broad ligament hematoma
 
FINDINGS:
Left broad ligament hematoma with bleeding vessels
 
SPECIMEN:
None
 
PROCEDURE:
 
Called in and incision already made and c-section was complete. Examination showed left broad ligament hematoma. The left retroperitoneal space was then opened and the ureters were identified. The hematoma was evacuated. hemoclips were used to obtain hemostasis of bleeding vessels. Once hemostasis noted then fibrillar and arista was placed in this space. Re examination showed hemostasis. Case returned to Dr. X for closure.
 
 

Comments (1)
Posted By Melanie Witt on 12-04-2019, 16:09:16
The code would be 49010, but you will have to add a modifier -52 as the surgeon did not open or close.
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