AHA Coding Clinic® for ICD-9 - 2007 Issue 2; Ask the Editor

Incidental Serosal Tear

The patient presented with a left upper quadrant retroperitoneal cystic mass, involving intra-abdominal organs and was brought to the operating room where she underwent radical excision of retroperitoneal cystic mass with adrenalectomy. During the procedure, the surgeon noted, “a small capsular injury of the spleen, which was hemostatic.” This injury did not require repair. An esophagogastroduodenscopy (EGD) was then performed for evaluation of the distal esophagus since the mass had adhered at the gastroesophageal junction. The EGD revealed a serosal injury to the stomach, which was repaired with interrupted Lembert sutures. The surgeon did not include the intraoperative tears in the diagnostic statement? What are the appropriate code assignments? ...

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