# enterectomy/colectomy/lysis of adhesions



## BABS37 (Oct 1, 2012)

I need help with an OP  note. Not sure what's bundled. Any takers? So far, I have 44144 as everything else seems like it's included in that procedure. Am I close?

1. enterectomy with ileostomy formation
2. segmental right colectomy with mucous fistula formation
3. lysis of adhesions requiring 5 times the normal length
4. resection of mesenteric mass at the root of the small bowel mesentery

Vertical midline incision was made and sharp dissection was used to divide the fascia. Immediately underneath the fascia were multiple small bowel loops which were densely adherent to the abdominal wall. Tedious and meticulous counter traction and sharp dissection carried out over 4-5 hours was necessary to achieve complete enterolysis. The obstructive point was found to be a dense nodular mass not more than a cm or two in diameter which was at the root of the small bowel mesentery adjacent to the superior mesenteric artery. The small bowel was densely adherent to this nodular mass in multiple locations evenly spaced throughout the colon. The first area which was adhesed to this was not more than 16-20" distal to the ligament of Treitz and the distal most area of small bowel involvement was just proximal to the ileocecal valve. The cecum was also involved. Initially I felt it wasn't going to be possible to separate enough small bowel from the mass to maintain enough small bowel to be life sustaining and the possibility of bringing up extremely proximal diverting loop jejunostomy for palliation was considered but further dissection around the root of the mesentery revealed a plane through which the majority of small bowel could be separated from the lesion and this was done. The small bowel was then divided with the GIA stapler at the mid ileum and a densely adherent portion of small bowel was resected dividing distally with the GIA as well as taking the mesentery with the harmonic. The tumor nodule was debulked as much as possible and resected with electrocautery although portions which were adherent to the SMA were left in place. The nodular mass was handed off and submitted separately to pathology. The involved portion of the right colon was resected by stapling distally with the GIA and the mesentery was divided here as well with the harmonic and this was handed off after mobilizing the colon medially and ensuring identification of the right ureter. Due to her advanced age and several episodes of intraoperative hypotension as well as extremely prolonged operating time I didn't feel that anastomotic creation was a viable option and locations were chosen for an ileostomy and mucous fistula on the right abdomen. Circular incisions were made and extended down through the fascia which was opened wide enough to admit two fingers. The distal ileum was delivered through the lower ostomy site and ascending colon was delivered through the upper ostomy site. Thorough irrigation was undertaken. Hemostasis was confirmed.


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## pamsbill (Oct 1, 2012)

Well you are a CPC and I am not (yet) but I would say you are probably correct with regard to the CPT.  I would most definitely add a 22 modifier and fight for extra reimbursement since the physician did an excellent job of describing the complexities involved with this case.  S/he even detailed the extra time involved which is excellent for fighting for the 22 modifier.  It stinks that the lysis of adhesions is inclusive to the 44144 but I truly think you can get extra compensation through the use of the 22.


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## BABS37 (Oct 1, 2012)

Thank you thank you! I'm not great with these surgeries though lol! It takes me forever to figure out the coding so I like to see if I'm on the right track with these. Yep- I had the 22 for sure  I just feel like when he does these, he's missing out on reimbursement. Seems like a loss and trying to explain these to him can sometimes be hairy as to why he can't bill for everything. Thank you so much for the help!!!!!


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## colorectal surgeon (Oct 1, 2012)

consider this also:

49203 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less


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## BABS37 (Oct 2, 2012)

Oh I like that code! You're awesome at these! Thanks for your help colorectal surgeon!!!


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