Open Appendectomy
44950
-
44960— Appendectomy for ruptured appendix with abscess or generalized peritonitis -
44955— Appendectomy, when done as incidental procedure — add-on
Acute appendicitis
Acute appendicitis [uncomplicated / perforated / gangrenous]
Open 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 clinical/imaging findings consistent with acute appendicitis. The risks, benefits, and alternatives 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. The cecum and terminal ileum appeared [normal / inflamed]. [Additional findings or none].
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, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. A right lower quadrant [Rocky Davis transverse / McBurney oblique] incision was made at [McBurney's point / one-third of the distance from the right anterior superior iliac spine to the umbilicus]. The incision was carried through the skin, subcutaneous tissue, external oblique aponeurosis, internal oblique, and transversus abdominis muscles using muscle-splitting technique. The peritoneal cavity was entered sharply and any fluid was cultured.
The cecum was identified and delivered into the wound. The appendix was located by following the taeniae coli to their convergence. The mesoappendix was sequentially clamped, divided, and ligated with [2-0 Vicryl / 2-0 silk] ties, securing the appendiceal artery. The base of the appendix was crushed with a hemostat, ligated with a [0-chromic / 0-Vicryl] tie at the crushed base, and the appendix was divided distal to the tie with a scalpel. [A purse-string suture was placed in the cecal serosa and the stump was inverted.]
The right lower quadrant was irrigated with warm saline. Hemostasis was confirmed. The peritoneum was closed with [3-0 Vicryl] running suture. The internal oblique and transversus abdominis were reapproximated with [3-0 Vicryl]. The external oblique aponeurosis was closed with [2-0 Vicryl] running suture. [For perforated cases: the skin was left open and packed with moist gauze.] [For clean cases: the skin was closed with [staples / 4-0 Monocryl] subcuticular sutures.] Sterile dressings were applied.
None
Appendix sent to pathology
Minimal (less than 30 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: Open 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 findings consistent with acute appendicitis. Informed consent was obtained.
FINDINGS: The appendix was ***. *** fluid in the right lower quadrant.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. A surgical timeout was performed per protocol.
A right lower quadrant *** incision was made. The peritoneal cavity was entered via muscle-splitting technique. The cecum was delivered and the appendix identified. The mesoappendix was divided and ligated, securing the appendiceal artery. The appendiceal base was ligated with *** and divided. The right lower quadrant was irrigated until clear. Hemostasis confirmed.
The wound was closed in layers. Skin was ***. Sterile dressings 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 with Abscess
The appendix was found to be perforated with a periappendiceal abscess containing [purulent/feculent] material. The abscess was evacuated and the field was copiously irrigated. The appendix was removed as described. Given gross contamination, the skin was left open and loosely packed with moist gauze for delayed primary closure. A [Jackson-Pratt drain was/was not] placed in the right lower quadrant.
Retrocecal Appendix
The appendix could not be identified in the right lower quadrant. The cecum was mobilized by dividing the lateral peritoneal reflection (white line of Toldt). The appendix was found in a retrocecal position adherent to the posterior cecal wall. Careful dissection freed the appendix and the procedure proceeded as described above in a retrograde fashion.
Charting Tips
- Specify incision type (Rocky Davis vs. McBurney), as this is in the operative record and affects any future RLQ incisions. Rocky Davis gives better exposure for complicated cases.
- For perforated cases with open wound, document that delayed primary closure was planned and skin packing was performed. This is important for wound care orders and patient counseling.
- Document whether purse-string inversion of the stump was performed. This is a point of variability that attending surgeons have strong preferences about and should be in the record.
Billing Tips
- Bill 44950 for open appendectomy, not ruptured (10.34 wRVU, 90-day global). Use when appendix is removed open without perforation or generalized peritonitis.
- Bill 44960 for open appendectomy with ruptured appendix and generalized peritonitis (14.14 wRVU). Document perforation, feculent/purulent contamination, extent of peritoneal involvement, and washout performed.
- Do not bill 44950 and 44960 together. Code selection is based on intraoperative findings. If perforation is found after opening, use 44960 regardless of preoperative impression.
- 90-day global period: wound care, IV antibiotics management, and drain follow-up are bundled. IR-placed drain for postoperative abscess within the global period is separately billable by radiology, not the surgeon.
- If incidental appendectomy is performed during another primary procedure (e.g., gynecologic case), use 44950 with modifier -51. Some payers bundle incidental appendectomy, so document the indication (e.g., mucocele, endometriosis, chronic inflammation) to support separate billing.