# Laparoscopic repair of parastomal hernia



## ksb0211

Just hoping that someone might be able to point me in the right direction on this one.  I'm hoping that I can avoid an unlisted code.
Thanks for any input or thoughts on this one.

PREOPERATIVE DIAGNOSIS
Parastomal hernia.  569.89
POSTOPERATIVE DIAGNOSIS
Parastomal hernia.  569.89

OPERATION PERFORMED
Laparoscopic repair of parastomal hernia utilizing AlloMax graft in Sugarbaker technique.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR.  After induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.  The patient has a permanent colostomy status post APR for carcinoma of the rectum.  She has developed a significant left lower quadrant parastomal hernia.  Repair is planned.

The initial incision was made in the right upper quadrant with a #15 blade.  The Optiview port was utilized.  The abdominal cavity was entered utilizing the Optiview technique.  There was no underlying bowel or vascular injury.  Two additional ports were placed, another 5 port and a 10/12 port.  With this completed, the patient was noted to have significant omental adhesions which were taken down from the midline.  Once this was done I was able to better visualize the hernia.  There were adhesions of colon to the abdominal wall in the left lower quadrant.  These were taken down.  The bowel was reduced from the hernia.  The hernia defect was noted to be significant, probably 6 cm in diameter.  The bowel was eventually well mobilized.  Once this was completed, the hernia defect was closed somewhat utilizing a suture passer and interrupted sutures of #1 PDS.  The defect was decreased in size significantly, though it did not impinge significantly on the bowel itself.  The decision was then to utilize an AlloMax graft.  The Sugarbaker Baker technique was utilized.  The 13 x 15 cm graft was passed intraabdominally.  The ProTack stapling device was utilized and the graft was secured laterally to the abdominal wall, bringing the residual left colon up to the level of the wall.  The graft then covered the site of the hernia and draped towards the midline.  This was all secured well with a double row of the ProTack stapler.  Stay sutures of 2-0 Prolene were also utilized to help secure the graft and maintain its position.  Once this was completed, the abdominal cavity was inspected for hemostasis.  There was no evidence of bowel or vascular injury.  The 10/12 port site was closed with 0-Monocryl suture.  The wounds were then closed with clips.  Dry sterile dressings were applied as well as a binder.  The patient tolerated the procedure and was taken to recovery room in stable condition.


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## Lujanwj

Take a look at 49655.  The soma site would be equal to an incision.


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## lindacoder

I dont agree with that.  I always use 44346.


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## Lujanwj

You can use whatever code you'd like but I'll give reasoning why 44346 is incorrect. 

44346 - Revision of colostomy; with repair of paracolostomy hernia.  

This code is for an open procedure, OpNote says Laps. Per AMA code must describe Laparoscopy in the description in order to use.  Code also requires work/revision to the stoma as well as a repair of a parastomal hernia.  Must do both, not just repair of parastomal hernia.  OpNote doesn't suggest revision to stoma, just repair of the incision site that the stoma came through.

These are only suggestions and I hope it helps.  

Good Luck!


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## sandralnorris

Unfortunately, I have always used the unlisted code when my doctors do a Lap Peristomal Hernia Repair.


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## cmartin

I would go with laparoscopic incisional hernia repair as well.


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## colorectal surgeon

I would also use lap incisional hernia.  Last time I checked, there is no ICD-9 code for parastomal hernia.  It is coded as an incisional hernia.


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## Venkatakrishnan

I agree with Laparoscopic incisional hernia repair.


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## acf7575

*laparoscopic parastomal hernia repair*



colorectal surgeon said:


> I would also use lap incisional hernia.  Last time I checked, there is no ICD-9 code for parastomal hernia.  It is coded as an incisional hernia.



ICD-9-CM code 569.69 covered colostomy and enterostomy complication including fistula, hernia and prolapse.  For current ICD-10-CM there are codes K43.5, K43.4 and K43.3.  I am not sure I am in agreement with the incisional hernia repair code because there is a specific paracolostomy hernia repair code for open procedures, the 44346.  While it does include revision of the colostomy, if you were doing it open you could easily use the reduced services modifier on that code.  Since there is not a laparoscopic version of code 44346 (Revision of colostomy; with repair of paracolostomy hernia (separate procedure)), we use unlisted procedure code 44238.  Maybe we are overthinking it, but is the incisional hernia not the "next best code" choice since there is an open repair code for the paracolostomy hernias?  We get it, ultimately it is an incisional hernia, but there is a specific open code.  Thanks!​


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