# 44143 (Hartmann's procedure), 49020 (I & D), 44955, & 49322 (need help on 49322)



## nlbarnes (Apr 13, 2016)

*44143 (Hartmann's procedure), 49020 (I & D), 44955, & 49322 (need help on 49322)*

44143, 49020, 49322, & 44955.  49322 is for lap and I can't find an open code??

PROCEDURES:                                                                                                                          
1.  Diagnostic laparoscopy.                                                                                                          
2. exploratory laparotomy                                                                                                            
3.  Hartmann's procedure.                                                                                                            
4. drainage of intra-abdominal abscess.                                                                                              
5.  Appendectomy    

via laparoscopic approach impossible.  The decision was made to convert                                                            
the procedure to open.                                                                                                             

Bovie cautery was used to make a 30 cm vertical   incision.                                                                        
  The incision was carried down through the subcutaneous fat, until the                                                            
linea alba was identified.                                                                                                         
The fascia was incised and linea alba, and the peritoneal cavity was                                                               
entered.   severe inflammatory                                                                                                     
adhesions were found in the pelvis and the left lower quadrant.                                                                    
The adhesions were broken by blunt dissection.                                                                                     
Approximately 30mL abscess was encountered medially                                                                                
to the sigmoid colon.  The sample of the purulent exudate was                                                                      
obtained and sent for cultures.                                                                                                    

 The sigmoid colon was carefully                                                                                                   
mobilized off the lateral abdominal wall and the peritoneum was                                                                    
Incised on the white line of Toldt allowing for better                                                                             
mobilization of the sigmoid colon.  The dissection continued                                                                       
cephalad along the lateral side of descending colon, which was                                                                     
 mobilized lateral to medial fashion.   After                                                                                      
descending and sigmoid colons were completely mobilized, the                                                                       
attention then was turned to the pelvis and the distal sigmoid                                                                     
colon was dissected towards the upper rectum.  The left ureter                                                                     
was identified and no injury to the ureter was noted.  The window                                                                  

in the mesorectum was then performed at the junction of sigmoid                                                                   
colon and rectum, and with the help of harmonic device.  The 60                                                                   
mm green load of Echelon Endo GIA stapler was then used to staple                                                                 
off the distal sigmoid colon from the upper rectum.  Adequate                                                                     
staple line was noted with no evidence of bleeding or bowel                                                                       
content leak.  The mesentery of the sigmoid colon was then                                                                        
transected with an Enseal device going cephalad .  The                                                                            
sigmoid colon was then completely mobilized to the distal                                                                         
descending colon, which did not appear to be involved in                                                                          
diverticulitis/diverticulosis.                                                                                                    

the entire small bowel was then examined from the ligament of Treitz to                                                           
the ileocecal area,                                                                                                               
And was found to be grossly normal.  The appendix was found to be                                                                 
secondarily inflamed,                                                                                                             
And decision was made to perform an appendectomy.                                                                                 
Another load of Endo GIA 60 blue load stapler was used to staple off the                                                          
appendix at its base.                                                                                                             
The mesentery was controlled with Enseal device.  No bleeding from the                                                            
appendiceal vessels was encountered.                                                                                              


 The abdominal cavity was then carefully irrigated with                                                                           
large amount of warm normal saline solution, which was suctioned                                                                  
out until clear return of the irrigation fluid was obtained.  A                                                                   
 19-French Blake drain  was placed through the 5 mm port                                                                          
insertion sites and  positioned in the pelvis.                                                                                    

The 10 blade scalpel was then used to make 3 cm in diameter, round                                                                
incision in the left lower quadrant.  The left rectus muscle fascia                                                               
was then excised with Bovie cautery.  The muscle                                                                                  

splitting incision was performed in the left rectus muscle                                                                       
  and the peritoneum was incised with Bovie cautery.                                                                             
The medium Alexis wound protector was then place to decrease the risk                                                            
of wound infection. The sigmoid colon was then brought into the wound.                                                           
  The second load of Endo GIA 60 mm                                                                                              
blue load stapler was then used to staple off the specimen which                                                                 
was  passed off the operating table.                                                                                             
The staple line again                                                                                                           
appeared to be hemostatic and patent.  The fascia then was closed                                                                
With a running #1PDS suture.  The colon was then                                                                                 
sutured to the edges of the fascia with several interrupted                                                                    
3-0 Vicryl sutures.  The wound was irrigated with warm normal                                                                    
saline solution.  Meticulous surgical hemostasis was achieved.                                                                   
The wound appear to hemostatic.  The staple line was then excised                                                                
with Bovie cautery and the ostomy was formed by suturing the                                                                     
edges of the bowel to the subcuticular tissue with 3-0 Vicryl.                                                                   
The ostomy appeared to be patent with no evidence of bleeding.                                                                   

Ostomy appliance was placed.


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## CodingKing (Apr 13, 2016)

HI, I'm a beginner at this just giving it a try since I don't get to do any real world coding. I cant figure out which portion of the procedure yiou are trying to report?

You already have codes for the following

3. Hartmann's procedure. 
4. drainage of intra-abdominal abscess. 
5. Appendectomy


The following are not reimbursable

1. Diagnostic laparoscopy. (not coded as converted to open procedure, if it didn't convert to open this would have been bundled into the other laparoscopic  procedures)
2. exploratory laparotomy (Not coded as its bundled into surgical procedure)


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