# Hemicolectomy help



## bda23054 (Jun 7, 2012)

I need help coding this extended hemicolectomy.  no anastomosis performed.  no closure.
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Preoperative diagnosis acute abdomen 
postop diagnosis perforated colon.

Procedure is exploratory laparotomy, extended right hemicolectomy.

Anesthesia Gen. endotracheal
Estimated blood loss 100 mL
Findings purulent peritoneal fluid.  Dusky  distal small bowel and right colon.  Inflammatory changes around the hepatic flexure of the colon with perforation.

Brief history.  69-year-old gentleman who has been having abdominal pain.  This morning his pain had increased and he had signs of peritonitis.  The decision was made to proceed to the operating room for exploration.

Details of procedure.  Patient was taken to the operating suite and placed in the supine position.  Preoperative antibiotics were given consent obtained.  SCD is applied.

After general anesthesia was induced his abdomen was prepped and draped in the normal sterile fashion.  A central line was placed by anesthesia.

A vertical midline incision was made with a scalpel and the cautery was used to the fascia.  The fascia was opened sharply and the peritoneal cavity entered.  Upon entering the peritoneum there was purulent fluid seen.  The small bowel was inspected and was free of perforation.  The liver and gallbladder were inspected.  There was some adhesion adhesions to the gallbladder which were taken down sharply.  The gallbladder was contracted and not perforated.
There were some inflammatory changes around the hepatic flexure of the colon.
We mobilized the right colon and as we were mobilizing the hepatic flexure of the colon a perforation was identified.  It was controlled with 3-0 silk suture.
The mobilization of the colon was performed to the mid transverse colon.
We then inspected the remainder of the colon down to the sigmoid and it appeared normal.
The decision was made to perform an extended right hemicolectomy as this portion of the colon was dusky and had perforation in it.
The mesentery was elevated off the retroperitoneum and the small bowel divided at the terminal ileum with a GIA-75 stapler.  The mid transverse colon was also divided with the GIA-75 stapler.  The omentum was taken down off of the proximal transverse colon with electrocautery.
The mesentery of the colon was then divided using the LigaSure system and the specimen removed.
The middle colic and right colic vessels were oversewn with silk suture.
At this point the abdomen was irrigated with sterile saline.  Hemostasis was achieved.  No other abnormalities were noted.  The distal small bowel appeared fairly dusky so the decision was made not to perform an anastomosis today but to reinspect after 24-48 hours.
He ab-thera wound VAC system was placed intra-abdominally and covered with the occlusive dressing.

- - two days later exploratory laparotomy
- - two days after that another exploratory laparotomy
- -  it was decided to do an end ileostomy and abdominal wall closure.


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## Lujanwj (Jun 11, 2012)

This one is definitely debatable but I'd try.  

Day one: 44144-52.  -52 for no closure and no mucofistula.  

Day two: 49999-58.  Dr isn't doing a true "reopening" because the patient was never closed.  

Day three: 44144-52-58 (-52 no mucofistula, again) Or 44310-58 -either code will include the closure.  I like to code the procedure that is staged for both the start and finish while others like to code the components of the staged procedure.  I've never seen good documentation (AMA or CMS) on how to code staged procedures.  *If someone out there has some, please post.

Either way, it's going to be reviewed.


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## bda23054 (Jun 18, 2012)

So you wouldn't use the 49002,58 for second look days later?


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## bda23054 (Jun 18, 2012)

Also, there was no anastomosis performed.


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