The completed open bowel operation

Plan

Fictional outpatient operative record describes elective laparoscopic sigmoid colectomy for a documented benign stricture. The decision to resect has already been made before surgery. This is a therapeutic operation, not a diagnostic laparoscopy to decide whether any open treatment is needed.

Attempted approach

After port placement, the surgeon begins mobilizing the sigmoid colon. Dense fixation prevents safe completion through the laparoscopic approach. The report records the limitation and conversion to a midline open approach during the same encounter. No separately indicated operation at another site is performed.

Completed anatomy

Through the open approach, the surgeon removes the diseased sigmoid segment and completes a colorectal anastomosis. No stoma is created. The report describes a completed resection and restored bowel continuity, followed by routine closure. These details guide review of the complete authorized entry.

Claim audit

The draft lists an open sigmoid resection and the attempted therapeutic laparoscopy. A suggested revision relabels the attempted laparoscopy as diagnostic. Evaluate both proposals using the conversion rule, while preserving the actual attempted approach and reason in the clinical record.

Your coding worksheet

1. Identify the planned and completed approaches.
2. Map removal and reconstruction.
3. Evaluate the attempted laparoscopy line and proposed relabeling.
4. Locate the full entry for the completed operation.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.