# need help with codes! takedown colostomy and closure of colostomy



## jcoder1

I am new to coding for gastro and would like to bounce this off someone who knows this better, than me. please read op note. a little confused! Need help finding the codes. thanks!

PROCEDURE:  This procedure is for the takedown of colostomy and closure of
colostomy.  The abdominal wall closure will be dictated by 
PREOPERATIVE DIAGNOSIS:  Status post Hartmann procedure with recurrent
periumbilical hernia and large parastomal hernia.

PROCEDURE:  Procedure for this portion is exploratory laparotomy, lysis of
adhesions, takedown of colostomy, and closure of colostomy.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Approximately 200-150.

FINDINGS:  There was no leak from the new anastomosis when tested by rigid
sigmoidoscopy.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room
via stretcher placing on the operating table in supine position.
Compression boots were placed.  General endotracheal anesthesia was
instituted.  A sterile indwelling Foley catheter and nasogastric tube were
passed, and the abdomen was prepped and draped in the usual fashion.  A
final time-out was performed.  Local anesthesia was infiltrated to the
midline, and a midline incision from just below the xiphoid to the pubis
was done excising the old midline scar with a 10 blade.  Bovie cautery
achieved hemostasis in the subcu and the virgin area of the abdomen was
entered in the superior portion the incision through the midline fascia
into the free peritoneal cavity, and the rest of the incision was opened
from top to bottom, with actually very little adhesions to the
paraumbilical hernia, and completely opening the incision.  At this point,
a complete lysis of adhesions was performed with the entire small intestine
being freed from the ligament of Treitz to the ileocecal valve.  The
appendix was still in place.  It was small and atretic and was not
addressed.  At this point prior to taking down the colostomy, the rectal
pouch was dissected with dividing the adhesions to the rectal pouch.  The
two Prolene sutures that were used to tack each corner of the staple line
were easily identified and delivered out of the wound, and now the rectal
pouch was dissected.  The mesentery proximally was divided with the
Harmonic Scalpel, and the pouch itself was dissected from the surrounding
scar tissue of the pelvis to the presacral space and laterally to the
rectal stalks.  Both ureters were identified and not harmed during the
dissection.  With an adequate length on the rectal pouch, it was elected to
first try a transanal anastomosis.  Glucagon 1 mg was given to the patient
and a contour stapler was applied to the end of the rectal pouch and fired.
The contour staple line was oversewn with a 2-0 Prolene and any redundant
scar tissue over the stapler was handed off the field.  The colostomy was
now taken down by excising the stoma from the surrounding left lower
quadrant skin with a 10 blade, deepening the incision with Bovie cautery
through the abdominal wall, and then releasing it from the abdominal wall.
The end of the stomach had been sutured closed prior to beginning the case
with a 2-0 silk suture in a pursestring stitch type fashion.  Some
adhesions to the large parastomal hernia from the descending colon were
divided with the Harmonic Scalpel LCS, allowing the stomach to be brought
intra-abdominally and then the descending colon was dissected and the
entire splenic flexure was now also mobilized with the Harmonic Scalpel LCS
to allow extra length on the descending colon to be brought down into the
pelvis.  At this point, the open end of the descending colon was sized and
it easily permitted at 28 Sizer to be placed.  Therefore, a 29 Sizer was
placed after serial sizing and the anvil of the 29 CEA stapler was placed
into the open end of the descending colon that had a pursestring suture
applied to it, tying the pursestring suture and holding the anvil in place
in the descending colon.  The patient was now placed in dorsal lithotomy
and the perianal area was prepped and draped.  The circular stapler was now
placed transanally, and because of dense scar tissue the stapler perforated
to the left side of the staple line.  This approach was abandoned.  The
stapler was removed transanally and the open area of the rectal stump was
identified.  A suture was placed on the left lateral aspect of the opening
and on the right side of the opening, and further dissection of the
surrounding scar and perirectal fat was performed, and now this opening was
now chosen to be used for the new anastomosis.  The anvil end of the
circular stapler was removed from the descending colon and placed into the
rectal pouch through the opening, and a 2-0 Prolene suture was sutured
about it and tied holding the anvil placed in the rectal pouch.  A fresh
CEA 29 mm stapler was now placed so that the stapler was placed through the
open of the descending colon, and the trocar was brought out through the
antimesenteric side and matched to the anvil, closed and fired creating a
side-to-end descending colon to rectal anastomosis.  This was digitally
examined through the open end of the descending colon prior to completely
closing the open end of the descending colon with another application of
the contour stapler with a green load.  An atraumatic bowel clamp was now
placed on the descending colon, and the anastomosis was submerged in saline
and rigid sigmoidoscopy was performed insufflating through the rectum
through the fresh anastomosis into the descending colon distending the
descending colon, but no bubbling was noted, indicating an air tight
colorectal anastomosis.  All the irrigant was suctioned out of the pelvis
and Evicel was now applied to the anastomosis.  All laparotomy pads were
removed and the left upper quadrant and left gutter were checked for
hemostasis, which was complete.  With the field hemostatic and all sponge,
lap, needle, and instrument counts reported as correct, the midline skin
and the colostomy skin opening was closed with staples temporarily and
covered with a plastic drape, and the patient was placed back into a normal
supine position, and prepped and draped in preparation for his abdominal
wall closure by Dr....., which will be dictated by him.  He tolerated this
portion of he procedure well without any overt complication.


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## EricaR

Hello, 

I was going to say a 44626 Closure enterostomy w/resection and colo rectal anastamosis, however they Dr. did not perform a resection.  In light of that we feel the best coding of this procedure would be 44626 with a 52 for reduced services since there was no resection.  Hope that helps.  

Erica, CPC


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## jcoder1

Hi Erica, thank you so much for taking a look.  Ito owas thinking 44626, but i think i talked myself out of it, so 44626 with 52. I was thinking of billing 44139 moblization of splenic flexure too?


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## EricaR

Jessee, 

No problem! Glad it was helpful, I tried to bill that too... you have to remember cpt 44139 mobilizing the splenic flexure is an add on code and can only be billed with 44140-44147. 

Erica


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