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The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger’s lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins. The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.
What CPT® coding is reported for the twin delivery?
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?