Laparoscopic Appendectomy
44970
-
44950— Converted to open appendectomy (incidental) -
44960— Appendectomy for ruptured appendix with abscess or generalized peritonitis
Acute appendicitis
Acute appendicitis [uncomplicated / perforated / gangrenous]
Laparoscopic appendectomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] presenting with right lower quadrant pain, leukocytosis, and CT findings consistent with acute appendicitis. The risks, benefits, and alternatives of the procedure, including nonoperative management, were discussed with the patient [and family], and informed consent was obtained.
The appendix was [mildly inflamed / markedly inflamed / gangrenous / perforated at the tip/base] with [serosanguineous/purulent/feculent] fluid in the right lower quadrant. [Free perforation with fecal contamination was/was not noted.] The cecum and terminal ileum were [normal / inflamed / wall-thickened]. [Additional findings or none].
The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. A small infraumbilical incision was made and pneumoperitoneum was established with a Veress needle to 15 mmHg. A 12-mm umbilical trocar was placed under direct visualization. Two additional trocars were placed under laparoscopic guidance: a 5-mm suprapubic port and a 5-mm left lower quadrant port.
The patient was positioned in Trendelenburg with left lateral tilt to facilitate exposure of the right lower quadrant. The appendix was identified at the convergence of the taeniae coli. The appendix was [mobile / adherent, requiring careful lysis of adhesions]. The mesoappendix was divided with [an energy device / between endoclips / with a linear stapler], controlling the appendiceal artery.
The base of the appendix was identified and confirmed to be at the cecum. The appendix was divided at its base with a [12-mm Endo GIA linear stapler / endoloop ligatures (x2 proximally, x1 distally)]. The specimen was placed in an endoscopic retrieval bag and extracted via the umbilical trocar. The appendiceal stump was inspected and appeared intact with no evidence of leak.
The right lower quadrant was irrigated with warm saline until return was clear. [In cases of perforation, the pelvis and right paracolic gutter were also irrigated.] Hemostasis was confirmed. The trocars were removed under direct visualization. The umbilical fascia was closed with [0-Vicryl] figure-of-eight suture. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Appendix sent to pathology
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Acute appendicitis
POSTOPERATIVE DIAGNOSIS: Acute appendicitis, ***
PROCEDURE PERFORMED: Laparoscopic appendectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with right lower quadrant pain and imaging consistent with acute appendicitis. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
FINDINGS: The appendix was ***. *** fluid in the right lower quadrant. The cecum and terminal ileum were ***.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, operative procedure, operative site, allergies, and administration of prophylactic antibiotics per protocol.
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established via Veress needle to 15 mmHg. A 12-mm umbilical trocar was placed. A 5-mm suprapubic and 5-mm left lower quadrant trocar were placed under visualization. The patient was positioned in Trendelenburg with left lateral tilt.
The appendix was identified at the convergence of the taeniae coli. The mesoappendix was divided with ***, controlling the appendiceal artery. The appendix was divided at its base with a linear stapler. The specimen was placed in a retrieval bag and extracted via the umbilical trocar. The stump was intact.
The right lower quadrant was irrigated until clear. Hemostasis was confirmed. Fascia was closed with 0-Vicryl. Skin was closed with 4-0 Monocryl. Sterile dressings were applied.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Appendix to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE — .TODAYVariants
Perforated Appendicitis
The appendix was found to be perforated at [the tip/the base] with [feculent/purulent] contamination of the right lower quadrant and pelvis. The mesoappendix was divided and the appendix was resected at the cecum with a linear stapler. The abdomen was copiously irrigated in the right lower quadrant, pelvis, and right paracolic gutter until return was clear. A [closed suction drain was/was not] left in the right lower quadrant.
Converted to Open
Due to [dense adhesions/retrocecal appendix/bleeding/unclear anatomy], the procedure was converted to open appendectomy. Pneumoperitoneum was released. A Rocky Davis (right lower quadrant transverse) incision was made through the external oblique, internal oblique, and transversus abdominis muscles. The appendix was delivered into the wound, the mesoappendix was ligated and divided, and the appendix was removed at its base with [ligatures/purse-string suture and inversion]. The wound was irrigated and closed in layers.
Incidental Appendectomy
An incidental appendectomy was performed at the time of [primary procedure] with attending surgeon approval. The appendix appeared grossly normal. The mesoappendix was divided and the appendix was removed at its base. Specimen was sent to pathology. The base stump was confirmed intact.
Charting Tips
- Document the gross appearance of the appendix explicitly — 'acute appendicitis' as a postoperative diagnosis should match what you saw: uncomplicated, gangrenous, or perforated. This determines antibiotic duration and billing complexity.
- For perforated cases, document the extent of contamination, which quadrants were irrigated, and drain placement rationale. Copious irrigation is a required documentation element.
- Stapler vs. endoloop for appendiceal base closure should be documented. If endoloops used, document that x2 were placed proximally and x1 distally.
Billing Tips
- Bill 44970 for laparoscopic appendectomy (9.21 wRVU, 90-day global). Use for uncomplicated acute or chronic appendicitis removed laparoscopically.
- Bill 44950 for open appendectomy (10.34 wRVU) if converted or performed open from the start. Do not bill 44970 and 44950 together.
- Upgrade to 44960 (14.14 wRVU) for perforated appendix with generalized peritonitis. Document frank perforation, feculent contamination, extent of peritoneal involvement, and washout performed — these details justify the higher-complexity code.
- 90-day global period applies. Drain management and wound checks within 90 days are bundled unless a separately identifiable service is provided.
- If a concurrent procedure is performed (e.g., lysis of adhesions, enterotomy repair), append modifier -51 and document each procedure separately in the operative note.