# Colovesical fistula, assistant surgeon, co-surgeon???



## ksb0211 (Jul 11, 2011)

Ok, so I'm trying to code out this surgery.  I am always confused when it comes to co-surgeon stuff.  My question is, when do you submit as co-surgeon as opposed to without?  Are there specific guidelines to that?  Also, since there is an assistant surgeon as well, how the heck do I differentiate?  Modifiers 62/80/ ugh....  LOL  Anyway, I'm going to post the op report hoping for input.  Thanks.


PREOPERATIVE DIAGNOSIS
Colovesical fistula, rule out small bowel enterovesical fistula.

POSTOPERATIVE DIAGNOSIS
Colovesical fistula with small bowel fistulization as well.

OPERATIVE PROCEDURE
Laparoscopic sigmoid resection with small bowel resection of the distal ileum with bladder repair performed by <urologist, another office> which will be dictated under separate copy.

SURGEON
<surgeon from our office>

FIRST ASSISTANT
<another surgeon from our office>

ESTIMATED BLOOD LOSS
Less than 100 cc.

PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion.
We made a 5 mm infraumbilical  incision, we entered the abdominal cavity with a Veress needle. We insufflated 14 mmhg, placed a 5 mm port. We placed another 5 mm port in the left lower quadrant and looked into the pelvis. We saw a lot of adhesions down there between the small bowel and the anterior abdominal wall and down onto the dome of the bladder. The sigmoid colon looked like it was also involved. Looking at this, it was hard to determine what was what. We just elected to put in a hand port coming just suprapubically. We went in and through the hand port, we resected the sigmoid off the bladder. There was a clear hole in the sigmoid and a lot of diverticular disease. Concurrent with that, the distal ileum was plastered up against this fistulized area and it was also fistulized as well. We separated the distal ileum from the sigmoid. At this point, we went back laparoscopically and mobilized the colon, mobilized it down into the pelvis and actually had a pretty good area of mobilization and could get enough length that we thought we could do a side-to-side type of anastomosis. We came back, opened through our hand port. The incision was no more than 7 cm. We brought the sigmoid colon up into the wound, transected with the GIA distally and another one proximally, we were able to get the two pieces of colon side by side, introduced the GIA and made a side-to-side colonic anastomosis between these two loops of bowel, then fired our stapler across it, a TA-60, across the rent and completed the anastomosis. We had taken down the mesentery with 2-0 silk ties. We then moved over to the small bowel. We saw that there was a bit that was fistulized, this was a relatively small area. We fired a GIA both proximal and distally and then made an anastomosis from the distal ileum onto the remains of the distal ileum and actually onto the cecum itself through the ileocecal valve. We closed that rent with the TA-60, but there was really very little mesenteric defect because the small bowel resection was quite small. We then irrigated copiously, aspirated, and called <Urologist> in to repair the clear cut fistula into the bladder. He did that in two layers and that will be dictated by him.
We then irrigated again, turned our attention to closure. We placed a Jackson-Pratt into the pelvis, and brought omentum down to cover the bladder repair and keep it separated from the colon and the small bowel repairs. Once that was done, we irrigated the wound quite copiously, closed with running #1 PDS, followed  by irrigation, followed  by 3-0 Vicryl followed  by skin staples. The patient tolerated  the procedure quite well.


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## surgonc87 (Jul 11, 2011)

You are advised to review other surgeon's op note for contradictions and coordinate coding with Urology coder so things are uniformed.  So far looks like the two main surgeons will report 44238 mod 62 and your primary surgeon and his assist will report 44202.

Primary surgeon
44238-m-62 ( take the fee for 44661 + 20% of original fee =  new fee for unlisted code) 
-description/ laparoscopic closure for enterovesical fistula with intestine resection
44202- enterectomy

Co-surgeon
44238-m-62

assistant 
44202-m-80

MS


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