# Roux-en-Y gastrojejunostomy



## lilleyea (Jul 11, 2017)

Does anyone know what code should be used for an open Roux-en-Y gastrojejunostomy? It was for gastric outlet obstruction. Here is the part of the op note in question:


"Once adequate adhesiolysis was performed, attention was turned to the stomach. The lesser sac was entered, and the stomach mobilized. There was dense adhesive tissue from the pylorus to the underlying head of the pancreas and porta. The decision was made that it was not safe to proceed with the proposed antrectomy for fear of injury to the portal structures and head of the pancreas. The decision was made to proceed with a Roux-en-Y gastrojejunostomy. The retrocolic space was performed. The site was selected after confirming the location of the ligament of Treitz. The GIA was used to divide the bowel, and the mesentery divided using the LigaSure system. The Roux limb was passed through the retrocolic space, and a side-to-side functional end-to-end anastomosis created from the stomach to the small bowel using the GIA stapler. The resulting defect was closed in layered fashion using 3-0 Vicryl in a running baseball fashion followed by a silk interrupted Lembert layer. The jejunojejunostomy was then performed using the GIA stapler. The resulting defect was also closed with a stapler and with a running Vicryl and silk stitch in an identical fashion. The NG tube was passed through the gastrojejunostomy into the Roux limb and secured at the nose. The abdomen was irrigated with copious amounts of warm normal saline until the effluent ran clear. At the completion of the procedure, the anastomosis was once again examined and found to be patent, adequate, and well vascularized. The closure was performed in a simple running fashion using a #1 double stranded PDS suture through all layers. The skin was irrigated, and meticulous hemostasis obtained. The skin was then closed using a surgical stapling device. At the completion of the procedure, the patient is pending transfer to the recovery room. She appears to be in stable condition. There were no complications, and all counts were said to be correct."


I can find the code for gastrojejunostomy 43820, but this does not describe the Roux-en-Y procedure. I have also found 43621 and 43633, but a gastrectomy was not performed. I am at a loss in how to code this. Any suggestions are most appreciated!


----------



## cgaston (Jul 12, 2017)

I would choose 43633.  They had to cut the lower portion of the stomach to create the anastomosis, so a partial distal gastrectomy was performed (IMHO).

"a side-to-side functional end-to-end anastomosis created from the stomach to the small bowel using the GIA stapler"


----------



## lilleyea (Jul 12, 2017)

Can I still use this even though the doctor said " The decision was made that it was not safe to proceed with the proposed antrectomy for fear of injury to the portal structures and head of the pancreas"?  Code 43633 description states that the distal portion of the stomach is removed (antrectomy), which in this case the doctor states he did not do.  Maybe I should just use an unlisted code?

Thanks again for your response


----------



## cgaston (Jul 12, 2017)

Here is the description of the procedure from the 2017 Procedural Reference Guide for Coders:

_The physician mobilizes the stomach and the first part of the duodenum by incising the peritoneum on the lateral aspect of the duodenum. He divides the duodenum between the clamps, just distal to the pylorus. The distal cut end of the duodenum is covered with gauze and kept aside for further anastomosis.  The distal cut end of the stomach and the duodenum are brought together without and tension between them. The seromuscular stitch is applied on the posterior walls of the two viscera and the bowel ends lie apart.  Stitches are tightened so that the seromuscular layers are in contact. _

It doesn't state that a specific portion of the stomach is removed -- just that the distal portion is (so it is open for interpretation, of course!). 

You could always use the -52 modifier for reduced services if you feel an antrectomy is required. Or you can just ignore me...I think I am thinking out loud at this point.


----------



## lilleyea (Jul 13, 2017)

Thank you very much for your help!  Those options sound like they will work


----------

