# Second Opinion needed on Multy procedure surgery



## dmaguire (Jul 29, 2011)

I am looking at an account where a provider in my practice was a co-surgeon on a case in which he stepped in when his specialty was needed.  A GYN surgeon performed a total hysterectomy then our General Surgeon stepped in and performed a Appendectomy, omentectomy and excision of a left pelvic sidewall tumor.  According to the documentation the tumor was in the infundibulopelvic ligament.  He divided the infundibulopelvic ligament  and then delivered the remnant of the infudibulopelvic ligament along with _some_ of the tumor.  Can you bill for that?  Also....if the provider previously did a total hysterectomy can we bill for the tumor?  is a suspensory ligament inclusive to the hysterectomy?  Any insight would be great.  

I am thinking we cannot bill for the appendectomy because according to the code book it states "Incidental appendectomy during intra-abdominal surgery does not usually warrant a separate identification.  If necessary to report, add modifier 52) or should I use the 44955?????  Also I am thinking you would not be able to bill for the "partial" removal of the tumor because he did not deliver the entire tumor?  

Thanks.


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## FTessaBartels (Jul 29, 2011)

*Please post the op note(s)*

*For an accurate response to surgical coding questions, please post the scrubbed operative note(s).*

From your brief description I do *not* believe you can code for the appendectomy at all. But, as stated above - can't really tell without seeing the entire note(s).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## dmaguire (Aug 1, 2011)

*Op Note*

*Preoperative Diagnosis: * Right adnexal mass; pelvic pain; elevated CA 125

*Operation:* 
1.  Total Abdominal hysterectomy & blunt & sharp dissection. 
2.  Appendectomy, infracolic omentectomy; excision of left pelvic sidewall tumor 

*Anesthesia:*  General

*Indications:*This 52 year old was brought to the operating room by her gynecologist for removal of an adnexal mass.  The patient had had vague symptoms of bloating, abdominal pain, and pelvic pain.  She did have an elevated CA 125.

*Findings:*Upon exploration the patient was noted to have adencocarcinoma that was metastatic in the peritoneal cavity. It appeared to be coming from the right ovary, but the patient had a lot of drop tumor in the pelvic surrounding the rectum.  The bowel was not prepped prior to surgery.  It was not completely clear what the patient had so we took the appendix to rule out mucinous tumor of the appendix.

*Procedure:*After the total abdominal hysterectomy and bilateral salipingo-oophorectomy were performed we explored the abdomen.  The patient had some bleeding from the infundibulopelvic ligament on the patient's left side.  The infundibulopelvic ligament was dissected out. We released some adhesions to it up by the sigmoid.  Ultimately, we dissected between the appendix and mesoappedndix at the cecal base and tied it off with 0 vicryl x2.  The mesentery of the appendix was taken down using the LigaSure device.  The specimen was thus delivered from the operative field.  

We turned our attention to the omentum.  The patient had some bulky disease in the omentum and an infracolic omentectomy was performed using sharp dissection,  electrocautery, and Ligasure.

Getting back to the infudibulopelvic ligament we were able to control the bleeding with a clamp.  We then dissected out the infudibulipelvic ligament all the way up to the pelvic brim.  We then excised with this infundibuloplevic ligament some tumor on the patient's left side.  We divided the infuldibulopelvic ligament with LigaSure.  We were able to deliver this remnant of the infundibulopelvic ligament along with some tumor from the operative field.

At this point I discussed things with Dr. X  Since the bowel was not prepped we did not feel we could safely remove the drop metastasis in the without getting into the rectum and having to do a bowel anastomosis, so we aborted any further intervention.  The procedure was brought to a close.

*Postoperative Diagnosis: * Right adnexal mass; pelvic pain; elevated CA 125


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## colorectal surgeon (Aug 1, 2011)

Please make sure your op notes are scrubbed and don't include names!


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## dmaguire (Aug 2, 2011)

*Appologies.*

I have removed the provider names.


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## FTessaBartels (Aug 3, 2011)

*44955*

I think the documentation shows an "indicated reason" for the appendectomy, so CPT 44955 is the code I would use (in addition to codes for other procedures).

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## dmaguire (Aug 4, 2011)

*Thank you*

Thank you for getting  back with me.  That is what I had written down but sometimes its nice to get validation from another coder.  

Danielle.


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