# Challenge=Multiple Procedures! HELP!!!



## brandyleigh23 (Jul 10, 2012)

I usually do Cardiology and our coder that gets Surgery is out! It is great to learn something new, but this has thrown me for a loop!! Can someone please help

PROCEDURE: After consent was obtained, the patient wa brought to the operating room and placed in the lithotomy posistion. She did recieve Invanz one gram IV, as well as Lovenox 30 mg subcutaneous preoperatively. A Foley catheter was inserted and the NG tube was inserted as well. I closed her colostomy with 0 silk in a figure of eight fashion. Her abdomen was then prepped and draped in the usual sterile fashion. The patient had a very large midline scar due to secondary intention of her prior open wound. Given this, I went straight through it all the way to her abdominal fascia. 

While opening up her miline abdominal fascia, I could easily identify approximately 3 to 4 incisional hernias, predominatly in the epigastric and periumbilical region. Once the entire incision was opened up, I then started to clear the lateral aspects of all of the adhesions which were quite dense. The bulk were taken with blunt and electrocautery. On the left lateral, I was able to free up the entire lateral wall from all of the abdominal wall adhesions, with only the ostomy in place. A similar fashion occurred on the right side taking down all of the abdominal wall adhesions. 

The adhesions were all the way from epigastric to pelvis . There were no noted bowel injuries. During my manipulation of the small bowel, it became quite clear that she had numberous large fluid filled cystic structures, with clear yellow fluid, likely contained thrombus. She did have one in the pelvis which anatomically was of concern for an ovarian cyst. 

Unfortunatley, this wall was accidentally entered into. Approx a 2 x 2 cm piece was sent. Intraoperatively Dr. Z stated no obvious epithilial cells, but could not exclude an ovarian cyst. During further manipulation, I felt I could feel the right ovary in the pelvis. In additon, the appendix was definitely adhered to the wall; thus, one of the large cysts was somewhat inflamed and given this, I ultimately elected to perform an appendectomy. 

The appendectomy was performed by cutting circumferentially around the base tying off with 2-0 wilks, dividing it and then dunking the base after coagulating with 3-0 silk in a figure of eight fashion. 

I then turned my attention to the colostomy and the patients descending colon. It appeared to be very vialbe. I then with my electrocautery carved inverted it back into the abdominal cavity. I did resect approx 2 to 3 inches of the distal colostomy given how ragged it appeared. This was performed with an GIA-75 blue load stapler. I then proceeded to identify my sigmoid and rectal stump. The patient did have a fair amount of adhesions, but all of these were easily taken down. The patitne did have approx 7 to 8 cm of her sigmoid remaining . To get further length of my descending colon, I did have to mobilize the splenic flexure. I did take the omentum down to transverse colon with my harmonic scalpel and took down all the abdominal wall bands. I paid very close attention not to injure the spleen or any other structures. Once the splenic flexure was mobilized, I had an over abundance of lenght into the pelvis.

Given the length of the sigmoid colon, I elected to resect the proximal 6t o 7 cm. This was performed by getting around it circumferentially and dividing with a contour Ethicon stapler. My descending colon had excellent reach into the remaining sigmoid/rectum. 

I then elected to proceed with an anastomosis with an EA stapler. An enterotomy was made on the distal descending colon. It was dilated up to a 29. I then placed an anvil and created a pursestring with a 2-0 Prolene. At this point in time, I went down below and serially dilated her rectum. I ultimately advanced the 29 EA stapler to the staple line of the rectal stump. The trocar was advanced. The trocar and the anvil were engaged and fired. I then chaecked to see if I had two donuts, which I did. Finally, I did perform an additional rigid proctoscopy. The distal colon was clamped. The pelvis was filled with air. I insufflated my ridged proctoscope and there was no air leak. I then removed the riid proctoscope. I did place approx 4 to 5 additional anterior 3-0 silk sutures to re-enforce the anatomosis staple line in a Lembert fashion. 

I then looked around the entire abdomen to make sure there were no missed injureis. There was good hemostasis. The entire abdomen was then copiously irrigated. 

I then turned my attention to the hernias, of which she had 3 or 4. We elected to place an underlay Biological A-cell 16 x 20 mesh. In order to do this, I created subcutaneous pockets approx 7 to 8 cm laterally on both edges. Once this was performes with my electrocautery, I the underlay mesh, wich had already been soaking for 20 to 30 min. was brought onto the field and placed posterior to the abdominal wall fascia. I then with 2-0 PDS sutures to U stitches to tack the mesh to the undersurgace very 3 to 4 cm. I used a total of approx 15 to 20 circumferentially. This covered all of the incisional hernias nicely and ultimatley allowed me to bring the abdominal fascia midline to close it primarity with a running 0 PDS suture x2. 

Prior to securing the A-cell Biological mesh, the prior colostomy site was closed with #1 PDS suture. Once the Biological mesh was securely tacked/tied down to the posterior abdominal wall, the abdominal fascia was closed with #1 PDS suture x2. The subcutaneous space was then copiously irrigated and checked for hemostasis. I did place two 10 French flat Blake drains on both sides and sercured them to the skin with 3-0 nylon stiches. At this point in time to reduce the chances of seroma, I did place an A-cell powder within the subcutaneous. 

Finally given the patients fairly large hyertrophic scar from her prior incision, approx a 1 cm edge ofskin removing scar from bith sides of my incision all the way from the epigastric to the suprapubic region was performed;thereby a scar revision. Length was 23 cm. Finally the skin edges which were hemostatic were then stapled close with multiple staples. The prior colostomy site was packed. The incision was then dressed with 4 x 4 gauze and secured with tape. There were no apparent complications. The patient lost approx 200 mL throughout the entire case. 



This doc used CPT's:
44005
44626
44139
44950
45300
49560
15777
13101
13102 x3

I understand some of these bundle and I am not at all familiar with a large procedure such as this. I am grateful to anyone that can help!!


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## cbaldia (Jul 10, 2012)

There are a lot of bundling issues going on, and some incorrect code choices.
I'll start with what appears correct:  44626 closure of colostomy w/resection, possible the 49560- it has a bundle relationship w/44626 but has a 1 in the modifier field in CCI, so you may be able to bill with a -59 modifier. 
Corrections: I would change the 44950 appy (which is bundled to the 44626) to a 44955 as there appears to be medical necessity for an incidental appy.
15777 should be 49568- read the green coding guidelines under this code for mesh wih ventral hernia repairs. 
Not billable: 44139 take down of splenic flexure can only be billed with codes in the 44140-44147 range. 44005 Lysis of adhesions is bundled and has a "0" indicator in CCI. 45300 proctoscopy has a separate procedure designation in CPT- and appears he used it to check his work. 13101, 13102 for complex closure- when you open them, ya gotta close em- not separately billable.  perhaps he was trying to bill for the scar removal as he had size listed for that .  I would also consider use of the modifier 22 as it appears that he spent some time lysis the adhesions-although he doesn't mention how much time.  If he feels this took a much longer amount of time, he should addend his op note to state as such and send a letter to the carrier explaining why.
Hope this gives you some direction, and a starting point.  I am interested in others input.
Good luck.


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## brandyleigh23 (Jul 11, 2012)

Thank you SO much. This really points me in a better direction

I will go over the report again and read my guidelines for hernias as you suggested.

Also, for anyone else reading this long report, here is the list of operations the doc dictated he performed:

OPERATIONS PERFORMED:
1. Extensive lysis of adhesions
2. Mobilization of splenic flexure
3. Reversal of colostomy, with additional sigmoidectomy
4. Appendectomy
5.Closure of incisional hernias with Biological mesh
6. Rigid proctoscope
7. Revision of hypertrophic midline scar, 23cm


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