# Lap Band Conversion to Sleeve



## Williealawishes (Jun 18, 2013)

I feel billing 43775 and 43774-59 would be appropriate.  I would love any other thoughts....



The abdominal wall of the patient was prepped and draped in the usual surgical fashion.. At this point  the surgical procedure was started.  The first step in the surgical
procedure was placement of a 12 mm port supraumbilical, 15cm from the xyphoid process.  In that previously selected area bupivacaine 0.5% was injected.  A 12 mm incision was made with an #11 blade.  A Veress needle was introduced through the abdominal wall fascia. Pneumoperitoneum was performed with insufflation of CO2 into the abdomen of the patient up to a pressure of 15 mmHg. The patient tolerated this very well with no evidence of any problems.  When the pneumoperitoneum reached an adequate pressure the needlle was removed and a 12 mm trocar was placed. Next a 10mm 30 degree scope was introduced into the abdominal cavity.  The liver seems to have a normal size.  The rest of the exploratory laparoscopy was normal. Next a 5mm and a 12mm trochar was placed into the RUQ and a 5mm and 15mm trocars were placed into the LUQ regions respectfully.  All trochars were placed under direct visualization without complication.  A Nathason retractor was next placed under direct visualization in the epigastric region to elevate the left lobe of the liver.


Next the band was visualized and found to be in appropriate position.  Using the Harmonic Scalpel the band was freed from the surrounding scar tissue.  Once completely mobilized, the band was unbuckled and removed from the abdominal cavity.
The gastric scar tissue that was underlying the band and constricting the stomach at this point was freed up using the harmonic scalped.  The gastric fundus was unrolled and flattened back out into its normal anatomical position.


At this point, we turned our attention to the gastrocolic ligament. Approximately 5 cm proximal to the pylorus the entry was obtained into the lesser sac by dividing the gastrocolic ligament using Harmonic Scalpel Once this was accomplished, we then were able to take down the gastroepiploic as well as the short gastric vessels, going from distal to proximal all the way up around the greater curve to the fundus and the left crus of the diaphragm at the angle of His. Once this was all freed up, a 36  french bougie was placed into the stomach hugging the lesser curve of the stomach. The tip was pushed toward the pylorus and the entire bougie was placed and pushed over to the lesser curve    We were then able to perform our first fire of the EndoGIA stapler using the green loads with seam guards, starting 5-6cm from the pylorus. .
Using this as a stent and guide, we were then able to perform serial fires of the EndoGIA stapler loaded with sequentially shorter staple loads. This was taken all the way up in a vertical fashion, all the way up to the angle of His, hugging the bougie along the lesser curve. The resected stomach was then pushed to the side. We then visualized the staple line an it was felt to be intact.  We then had anesthesia remove the bougie without difficulties. An oral gastric tube was then placed back into the stomach and an air leak test was performed.  No leaks were encountered. There was no evidence of bleeding. No evidence of any intra-abdominal complications.  The gastric remnant was next removed after dilating and extending the incision of the LUQ 12mm trocar site.  Next the catheter hub was removed from its subcutaneous position which was located adjacent to the 15 mm trochar site.  Using the same incision, electrocautery was used to free up the scar tissue from around the hub and the hub was removed.   Next the
Nathanson retractor was removed and all the ports were removed under vision.  At this point the area where the extraction site incision was closed at the fascia layer with interrupted sutures of 0-Vycril.  Pneumoperitoneum was resolved. The subcutaneous tissue was closed with subcuticular running suture of 4-0 Monocryl. 


The patient tolerated the procedure very well and there were no complications. The patient was woke up in the operating room and transferred to recovery room, awake, alert and in stable condition. Sponge, needle, and instrument counts were complete at the end of the case.


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## lindacoder (Jun 18, 2013)

When we pre-d these the insurance companies come back and say that they will not pay for removal of the band with conversion to a sleeve.  Guess it will depend on your payors but most of them will not allow it.


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## Williealawishes (Jun 18, 2013)

Do you feel that adding a 22 modifier to the the sleeve procedure is justified due to the time spent removing the band and ports?


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## MCook (Jun 19, 2013)

We are having this same issue and our doc is not happy.  He is writing the medical director of the insurance company to see if he can make an impact that way.  Modifier 22 is an option if the doctor documents the excessive time.  At least then the claim will have to be looked at and not just go through the automatic edits.


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## Williealawishes (Jun 19, 2013)

Regarding the 22 modifier....I thought this meant anything beyond the normal circumstances.  I question this because a normal sleeve does not include the full procedure of the band and port removal....so do you feel that I still need time documented?  I guess I rely on the time issue when something is excessive of the actual time.  With this procedure it is including another procedure which in my mine grants the 22 modifier since I am unable to unbundle it.  Another example I would use a 22 modifier without time documentation would be lap convert to open with extensive adhesions prior to opening.  Am I using this incorrectly??

Would love some thoughts....


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## hcg (Aug 8, 2013)

Williealawishes said:


> Do you feel that adding a 22 modifier to the the sleeve procedure is justified due to the time spent removing the band and ports?




We are having the same issue with all our insurance carriers. None of our claims got paid if we use 43774 with 43775. Have you guys tried modifier 22? I'm wondering if it got paid?


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