# Please help me figure this one out.



## ksb0211 (Oct 12, 2011)

Our surgeon was called into the operating room to assist with issues related to an attempted hysterectomy.  I'm trying to figure out the best way to go about coding this out.  Not only dissecting the op report for the cpt's themself, but as far as modifiers 80/62, etc.
The other physician's op report lists obviously him as primary surgeon, an assistant surgeon and then he lists my surgeon as "INTRAOP CONSULT"  UGH!!!!!  (I will include a portion of the primary surgeon's operative report at the end just for reference)
Thank you so much.

PROCEDURE
The patient is a 51-year-old female, a patient of Dr. <OB/GYN>.  In the course of an attempted hysterectomy, I was called into the operating room to assist.  The patient was noted to have a lot of adhesions and had had previous radiation therapy apparently for rectal carcinoma that she had in the past.  The small bowel was absolutely glued to the fundus of the uterus and we were able to take down a lot of flimsy adhesions, but there were several points at which the margins between the uterus and the bowel were just obliterated.  In an attempt to take those down, we fenestrated one portion of the bowel.  We controlled it immediately by firing staples both proximally and distally and the area that involved was probably about 5 cm but there was absolutely no margin and what I doing was using a scalpel to try to go through the uterus and leave the bowel alone and in the course of doing that, some of the traction resulted in a tear just above that area, not where we were actually operating.  We went over, got that down.  We were able to mobilize more of the gut away from the uterus and then came on the other side and we had a similar situation on that side.  On this side, we were able to get resected pretty well all of that off, but it was very, very dense and looking at it, we just realized that was not gut that we wanted to be behind it so we fired a stapler both proximally and distally.  This was remote from the other area so we resected two I would say 5 or 6 cm pieces of small bowel that had been densely adhesed to the uterus and then made an anastomosis using a GIA with 4.8 mm staples, fired the stapler down the lumen on both sides and closed the resultant rent with a TA-60 with green staples.  We then closed the mesenteric defect with running 3-0 Vicryl in both locations.  We then looked at the remainder of the uterus and as we looked down, the cul-de-sac was obliterated and just all of these structures, there was no margin, there were no surgical planes because of the radiation therapy that looked like that they were going to be amenable to dissection.  My comment to the gynecologist was that this patient could very well wind up with a colostomy that would be permanent if they persisted because the operative field was so altered and again, this is not something I say lightly.  The nature of these adhesions and being a busy general surgeon, these adhesions were very dense and probably as dense as I have seen a couple of years.  After I finished doing my resections, the dome of the uterus was freed, we could see that it was densely adhesed to the bladder anteriorly.  I left the decision whether to proceed with a total abdominal hysterectomy to the gynecologist but the feeling in the operating room was that they were going to stop their procedure and I think that probably was well advised.


Here is an excerpt of the primary physician's op report:
.....Upon entering the abdominal cavity, it was noted to be massive bowel adhesion with the anterior lateral side wall and also the uterus.  We attempted to do some lysis of adhesion but this was beyond our scope.  At this time, an intraoperative consult was called, general surgeon, Dr. XXXXX entered.  He will his portion.  Upon the completion of Dr. XXXXX doing the lysis of adhesions, small bowel resection and reanastomosis, it was determined that because secondary to the radiation and a massive adhesion, the large intestine was densely adhesed to the uterus and it would be best to terminate the case at this time.  The patient and made it was known that under no circumstances would she wanted colostomy and because of what was seen and history of radiation therapy, if we accidentally entered the large intestine, a permanent colostomy would be required.  So at this time we decided to end the procedure as her pelvic pain could be secondary to the dense adhesions.  The pelvis was then copiously irrigated and small bowel resection and anastomosis was noted to be intact.  At this time, the all sponge and instrument was removed from the patient's abdomen.  Instruments, sponge and needle count correct x2.  The fascia using a double looped PDS and the peritoneum along with the fascia and the rectus muscle was reapproximated.  Good hemostasis was noted.  The skin was then closed with staples.  The patient was taken to the recovery room in stable condition.


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## FTessaBartels (Oct 14, 2011)

*Small bowl resection*

I'd code this as the small bowel resection, with a -22 modifier for additional difficulty due to the extent of the lysis of adhesions.

As the codes you are using for small-bowel resection will not have anything to do with the OB-GYN code for the hysterectomy, you shouldn't need a -62 modifier. 

Your surgeon uses "we" a lot ... was he assisted by the OBGYN?  If so the OBGYN can bill the small bowel resection with an -80 modifier (or -82 if you are in a teaching hospital).


Hope that helps.

F Tessa Bartels, CPC, CEMC


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## ksb0211 (Oct 14, 2011)

Thank you so much.  I have been banging my head against the wall with this one.  The "we" was throwing me off as well.  LOL.


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