# Liver Biopsy during other open procedure



## ch81059 (Mar 11, 2014)

Hi,

I just need an opinion on this.  On the operative report below, I am thinking I need to code 43820, 47100 and 44015.  I'm particularly interested in making sure I coded the liver biopsy correctly.  I don't think I can code for the umbilical hernia repair since the incision had to be made anyway to perform the surgery.

PREOPERATIVE DIAGNOSIS
Periampullary cancer.

POSTOPERATIVE DIAGNOSIS
Locally advanced, non-metastatic, unresectable periampullary malignancy.

PROCEDURES
1. Exploratory laparotomy.
2. Liver biopsy.
3. Umbilical hernia repair.
4. Gastrojejunostomy.
5. Placement of 20-French feeding jejunostomy tube.

BLOOD LOSS
100 mL

ANESTHESIA
General endotracheal anesthesia.

SPECIMEN
Liver biopsies times 2.

INDICATION FOR PROCEDURE

Ms. xxxxxx is a 70-year-old female who presented to the hospital recently
with nausea, emesis, and obstructive jaundice. A workup ensued which
identified a periampullary mass. She subsequently underwent an EUSguided
FNA which proved this to be an adenocarcinoma. On crosssectional
imaging, her lesion appeared to be resectable. She was
offered a pancreatic head resection. Underwent a session in which the
risks, benefits, and alternatives were explained in detail. She signed
a written consent form agreeing to undergo this procedure.

REPORT OF OPERATION
The patient was brought to the operating theater. Endotracheal
anesthesia was induced. Her abdomen was prepped and draped in sterile
fashion.

On physical examination, the patient had a small incarcerated umbilical
hernia, and a midline incision was made from the xiphoid process to
below her umbilicus. Cautery was used to deepen the incision and
incised the linea alba, taking the incision down inferiorly. The
incarcerated omentum was freed from the hernia sac around the umbilicus
and dropped back into the abdomen. The Bookwalter retractor was brought
up onto the field and placed into the abdomen for permanent retraction.
Upon visualizing the liver, the liver appeared to be congested,
consistent with her known obstructive jaundice secondary to cholestasis,
and multiple small white nodules were appreciated. Two small 2-mm size
nodules were sent to Pathology for frozen analysis and both of these
were determined to be bile duct hamartomas and therefore benign.

Attention was then turned towards a Kocher maneuver. The congenital
attachments between the right colon and the hepatic flexure were divided
under direct visualization, enabling us to lower the hepatic flexure and
visualize the duodenum. The congenital attachments between the
retroperitoneum and the duodenum were then lysed, again under direct
visualization, enabling us to mobilize the duodenum medially, bringing
it up off the vena cava until we visualized the left renal vein. A very
large bulky tumor was appreciated within the pancreas extending up
towards the biliary confluence as well. The greater omentum was then
incised off the transverse colon, enabling us to enter into the left
lesser sac. In the transverse mesocolon, the middle colic vein was
identified and traced towards its confluence until the junction of the
right gastroepiploic vein and the middle colic vein was identified. A
mass lesion was appreciated at this junction puckering and distorting
the anatomy at this level. Care was taken not to injure either of these
veins, and dissection then ensued proximal to this mass lesion until the
superior mesenteric vein was identified. The superior mesenteric vein
was then identified, and interestingly an artery was noted to run
transversely over the SMV underneath the neck of the pancreas. A subpancreatic
tunnel was created underneath this artery and underneath the
neck of the pancreas for a distance of about 1 cm along the inferior
edge of the pancreas. Attention was then turned towards identifying the
portal vein on the superior aspect of the neck of the pancreas. The
stomach was grasped and retracted inferiorly, and the lesser omentum was
incised with cautery. In doing so, we could appreciate that the bulky
tumor mass within the pancreas was almost completely occluding the 1st
portion of the duodenum and was very adherent to the structures of the
porta hepatis including the hepatic artery. The duodenum was retracted superiorly. After multiple attempts, we felt it was not safe to make a
dissection plane in this area due to the advanced nature of her tumor in
this location.

At this point, a called one of my partners, Dr. xxxxxx, to enter the
operating room to render a second opinion. He evaluated the anatomy and
concurred that this lesion would not be amenable to a safe R0 resection.
At this point, we felt it reasonable to focus attention on a palliative
bypass rather than resecting the primary tumor.

As was mentioned previously, bulky tumor nodularity extended proximally
along the bile duct, and for this reason I felt it unsafe and
unnecessary to encircle it and perform a hepaticojejunostomy. But
because of her preoperative nausea symptoms, we felt that a
gastrojejunostomy would be appropriate.

A loop of jejunum was then brought up from the ligament of Treitz, and a
2-layer, hand-sewn, side-to-side Billroth-II gastrojejunostomy was
created between the posterior stomach and the proximal jejunum about 25
cm distal to the ligament of Treitz in an antecolic fashion.
Understanding that the patient would need a biliary drainage procedure
postoperatively and that this may have to be done during an endoscopic
approach that would risk stress on this gastrojejunostomy, I felt it
appropriate to place a feeding tube in the jejunum in order to protect
the anastomosis should this become an issue. Therefore, a spot about 30
cm distal to the gastrojejunostomy was chosen to place a 20-French
feeding tube. Two pursestring stitches of 2-0 silk were placed
circumferentially on the antimesenteric bowel, and an enterotomy was
made in the center of these 2 pursestring stitches. The J-tube was then
passed into the lumen of the intestines. The 2 pursestring stitches
were tied and the J-tube was then brought out extracorporeally through a
stab incision in the left abdomen.

At this point, we reinspected the abdomen and noted that hemostasis was
excellent. The aberrant artery that ran transversely over the SMV at
the inferior aspect of the pancreas was most likely an aberrant right
hepatic or an aberrant common hepatic artery. At this point, we felt it
reasonable to terminate the case.

The midline incision was reapproximated with a looped PDS, taking care
to close the previous umbilical hernia primarily. The skin was
reapproximated with staples. Prior to this, the abdomen had been
irrigated copiously with sterile water.

The patient tolerated the procedure without any immediate difficulty.
Needle and sponge counts were accurate for the duration of the case.  The patient was transferred to recovery room in satisfactory condition.

Include a large bulky periampullary tumor mass that was nearly occluding
the 1st portion of the duodenum causing the duodenum to be puckered and
retracted superiorly with prominent bulky portal lymphadenopathy
palpable and encasing the bile duct. This tumor mass appeared to encase
the proper hepatic artery and the GDA. In addition, she had an aberrant
arterial vasculature such that a large prominent artery was noted to be
running at the inferior aspect of the neck of the pancreas transversely
at a 90-degree angle to the SMV. This was traced back and noted to
arise directly from the aorta and was likely consistent with a replaced
common hepatic or an aberrant right hepatic artery, as it appeared to be
separate from the SMA which was inferior to it. Because of the locally
advanced nature of this tumor, we felt that a safe R0 resection would
not be possible on this occasion, and therefore a single
gastrojejunostomy was performed to relieve her symptoms of gastric
outlet obstruction. We will attempt to get a percutaneous or endoscopic
biliary drainage in the postoperative setting.


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## nrichard (Mar 11, 2014)

*More information is needed.*

I agree with 43820, and 44105. It appears that he was trying to do a resection of the pancreatic head with anastomosis between the billiary tract.  I would query the physician and find out which Whipple code to use with modifier 53 (discontinued procedure). See codes 48150-48155. (That?s a lot of money you?d be losing in not reporting that code).  Since some payers do pay for discontinued procedures, try submitting to insurance on paper with the op-note the first time around, if your payer will let you. 
I would suggest a query on the liver biopsy too, because it?s not stated how the ?two small biopsies? where obtained. 
Also you are correct about not being able to bill the umbilical hernia.


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