# 5 procedures, how many can get paid?



## hsmith67 (Oct 11, 2011)

OK, my doc did:
 exploratory laparotomy, greater than 2.5 hours of lysis of dense adhesions, cholecystectomy, takedown and closure of cholecystoduodenal fistula, and enterotomy with removal of gallstones from the ileum! I have to believe I can get him paid for something other than the lysis of adhesions or laparotomy! Please see below note and help is greatly appreciated. I will pick up the note once incision made:

Approximately 800 cc of ascites was evacuated from the abdomen resulting from the inflammatory process in the right upper quadrant of the abdomen. The omentum was adhesed to the anterior abdominal wall. This was lysed through a combination of blunt dissection and lysed with Metzenbaum scissors and Bovie. Once the omentum was released from the anterior abdominal wall, the incision was lengthened past the umbilicus to just proximal to the pubic symphysis. Once this was done, adhesions were found in the pelvis. Small bowel was stuck to the anterior abdominal wall, which was gently lysed with Metzenbaum scissors. Once the abdomen was full opened, a Bookwalter retractor was placed to provide adequate exposure in the abdomen. In the pelvis, there were noted to be dense adhesions of small bowel from her prior hysterectomy. The adenolysis continued for approximately 2 1/2 hours where each interloop adhesion and adhesed bowel were carefully lysed taking care not to injure the bowel. Once the bowel was mobilized from the pelvis and was brought into the operative field, the small bowel was freed from its attachement to the under surface of the omentum. The operation continued into the right upper quadrant where there was significant inflammatory reaction in the area of the duodenal bulb where the fistulous communication with the gallbladder was identified as well as several stones which could be palpated. Staying close to the gallbladder and beginning laterally, the ballbladder was bluntly dissected from its attachment to the liver on the left side. A plane between the medial side of the gallbladder was identified and using Metzenbaum scissors, this was carefully lyssed makind sure not to injure the duodenum. Once the plane was cleared, the cystic artery was identified and ligated with 3-0 silk sutures. The gallbladder wall was amputated and passed off the table as specimen. The opening in the fistulas in the small bowel was identified and defined. Allis clamps were placed on the edges of the bowel and the bowel was closed primarily with interrupted 3-0 silk sutures along its length. This area was very inflamed. The repair was then reinforced with omentum which was brought into the right upper quadrant from the transverse colon and it was then tacked in 5 positions with silk sutures completely reinforcing the repair of the duodenum. Once this was completed the abdominal cavity was then irrigated with copious amounts of bacitracin saline solution and then evacuated by suction. The bowel was palpated from the ligament of Treitz to the terminal ileum. There were gallstaones removed from the bowel through and etereotomy. There was very small soilage of ileal contents into the abodominal cavity. This was quickly cleaned up with lap sponges. This was some distance away from the ileocecal valve. The bowel was opened transversely  and closed longitudinally with sile sutures and reinforced with a Lembert stitch. Of note, when the fistula was separated from the gallbladder, several large gallstones and small stones were removed, approximately 5 to 7 in total. 

Soo, ideas/suggestions on how to bill this one?

Thanks,
Hunter Smith, CPC


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## hewitt (Oct 11, 2011)

The quick answer is as many as are medically necessary, and are not unbundled. Do you have software to help determine what is/is not bundled?


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## hsmith67 (Oct 11, 2011)

*unbundling software*

Hewitt,

No, I don't have any unbundling sofware. Can you suggest a specific package, where? 

Thanks,
Hunter Smith, CPC


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## Grintwig (Oct 11, 2011)

I am by no means an expert but I do code general surgery. In the office I work in we use Payer Path.
I have never seen a case like this before but I will give it a shot.
I came up with:
44602-22 repair of small intestine as the primary code ewith the 22 for all of the extended time and effort it took to get to them without causing further injury(as it has the highest reimbursement)
47600-59 for removal of the gallbladder
44020-59 for removal of the gallstones (foreign body) from the small intestine
47600 and 44020 are column one codes of 44602 per the CCI edits in Payer Path but can be used with a modifier.
You cannot code the laparotomy as there were other procedures done and the lysis of adhesions is bundled into the other procedures as well. I did include the 22 on the main procedure to account for the 2.5 hours spent lysing them. 
If there are other more appropriate codes I would love to find out what they are. This was a really tough one


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## hewitt (Oct 11, 2011)

Try this link, https://www.cms.gov/nationalcorrectcodinited/  Unfortunately, you will have to do some reading, but this is FREE.


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## hsmith67 (Oct 11, 2011)

*Thanks*

Thanks for your help hewitt and Grintwig!

I will review the link and don't mind reading if I can get it right the first time.

Thanks again,
Hunter Smith, CPC


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