# Expl Lap or Appendectomy Help Please



## bill2doc (Jan 17, 2012)

Can anyone help with the CPT's for this??? thank you in advance !

PROCEDURES: 
1.  Exploratory laparoscopy. 
2.  Laparoscopic omental patch of duodenal ulcer.   
3.  Incidental appendectomy.   

PROCEDURE IN DETAIL:  The patient was brought to the Operating Room and placed in supine position.  Standard timeout was performed between the Anesthesia team, the OR staff and the surgeon indicating the correct patient and the correct procedure.  Endotracheal anesthesia was then initiated, and the abdomen was prepped and draped in the standard fashion.  A curvilinear infraumbilical incision was then made.  This was carried to the fascia.  The umbilical stalk was then grasped and elevated and the fascia at its base was then exposed.  A midline fascial incision was then performed.  Heavy Vicryl was then placed on either side of the fascial defect.  A Hasson trocar was then introduced in the abdomen, and the pneumoperitoneum established.  The camera was then introduced, and of note, there is no evidence of bowel injury secondary to entry noted on initial observation.  Once the abdomen was entered, one of the first things noticed was the significant amount of purulent fluid that was throughout the abdomen.  Turning the scope around, it was in both upper quadrants over the dome of the liver and along the paracolic gutter, as well as in the pelvis.  The cecum was then identified, and the taenia traced to their confluence where the base of the appendix was visualized.  The appendix was grasped and elevated.  It appeared to be rather long but demonstrated no evidence of inflammation or injury.  The appendix was soft.  The surrounding fatty tissue did not appear indurated, and the appendix did not appear to be the cause of this inflammation.  A second examination of the remainder of the abdomen noted an inflammatory mass underneath the liver with the omentum moving into the right upper quadrant.  At this point three 5 mm ports were then placed along the costal margin.  The gallbladder was elevated and then retracted.  The pylorus was identified and gently retracted downward, and in the anterior aspects of the first portion of the duodenum, a small perforated ulcer was identified.  Examination of the remainder of the intraperitoneal duodenum identified no other sites of perforation leading to the conclusion that this patient did not, in fact, have a perforated appendicitis, but rather a perforated peptic ulcer.  The decision was made to perform a Graham patch maneuver, as there was a significant amount of healthy omentum available.  The abdomen was irrigated with warm sterile normal saline and retraction of the duodenum was performed to maximize exposure.  Vicryl sutures were then placed on either side of the perforation though healthy duodenal tissue and then laid open.  A tongue of omentum was laid over that Vicryl suture, which was then intracorporeally tied.  Once the omentum was in place over the ulcer itself, a second stitch superior to the ulcer was then placed through the healthy duodenal tissue and tied around the omentum.  The omentum was then tacked laterally over the ulcer as well.  Once the omentum fully secured, the abdomen was then copiously irrigated warm sterile normal saline until the irrigant ran clear.  Attention then turned back to the pelvis, where the mesentry of the appendix was then grasped and elevated.  It was divided with the ligature device.  The base of the appendix was elevated and exposed, and linear cutting stapler was then used to divide and close the appendix, which was then removed under direct vision.  The bowel was examined for evidence of other injury and all that was noted was small amount of inflammatory rind secondary to the purulent intraabdominal fluid.  The ports were then removed under direct vision.  The pneumoperitoneum was allowed to resolve.  The previously placed fascial sutures were then tied.  The skin was then closed with staples.  Dressings were then applied.  The patient was then allowed to waken from anesthesia and brought to the Recovery Room in good condition.


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## lindacoder (Jan 18, 2012)

I would not charge for the appendectomy as the op note clearly states it was incidental.  As for the omental patch of the duodenal ulcer, there is not a laparoscopic CPT code for this.  An unlisted CPT code would be 43999. When I use this code I send a letter stating that it is unlisted but there is a comparative open CPT code (43840). This usually saves time and gets the claim paid without delay. Hope this helps.


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## bill2doc (Jan 31, 2012)

Thank you for your help.  Would I price this unlisted procedure at the same rate as the 43840 to which I am comparing it to ?

Not familiar with unlisted codes. Thanks


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## tcooper@tupelosurgery.com (Jan 31, 2012)

*Unlisted Procedure*

I would use the Unlisted Procedure code 43659 since this was a Laparoscopic procedure. We usually charge more for Laparoscopic procedures. I would ask the Surgeon if he would like to charge above the charge for 43840. Also they did have an Omental Flap and this is an add on code so I would add more the unlisted code to cover the Omental Flap. I hope this helps. I do not like unlisted codes but sometimes that is our only option. 
Have a good day
Teresa


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