# Lap choly with lap appendectomy



## Trendale (Jul 5, 2011)

Hello,
Can these two be billed together with a mod 59 on the apepndectomy? Is the appendectomy considered incidental? The dx for it is 543.9 dialation. I thought I can, just wanted to make sure. Thanks!

DESCRIPTION OF PROCEDURE:  The patient was transported to the
operating room and placed in the supine position.  General
endotracheal anesthesia was administered.  The abdomen was prepped and
draped in usual sterile fashion.  The circulating nurse had called a
surgical time-out.  All members of the operative team were in
agreement with that statement.  Marcaine 0.5% with epinephrine was
infiltrated into the inferior umbilicus.  A vertical incision was made
in the inferior umbilicus.  The underlying fascia was grasped with
Kocher clamps, opened for a short distance in the midline.  The
peritoneum was also opened for a short distance in the midline.
Sutures of 0 Vicryl were placed through the fascia laterally.  The
Hasson cannula was inserted through the incision into the abdominal
cavity.  Sutures were tied around the cannula to create an airtight
seal.  A pneumoperitoneum was created with carbon dioxide to 15 mmHg.
A 5 mm 0-degree laparoscope with attached camera was placed through
the cannula.  Initial inspection of the lower abdomen and pelvis
revealed no significant abnormalities.  The appendix was visualized in
retrocecal position initially.  The mid portion of the appendix
appeared to be mildly dilated.  The tip of the appendix was
unremarkable.  The patient certainly did not appear to exhibit acute
appendicitis, although the mid portion of the appendix was somewhat
dilated.  The gallbladder was tense and distended in the upper
abdomen.  The stomach was decompressed.  The liver appeared to exhibit
some fatty change.  Under direct visualization, a 5 mm trocar was
placed in the epigastrium and two 5 mm trocars were placed in the
right upper quadrant.  Marcaine was infiltrated at each site prior to
trocar placement.  A long laparoscopic needle was used to attempt
aspiration of the gallbladder.  Only 20 mL of bile and several small
stone fragments were aspirated.  The fundus of the gallbladder was
grasped and the gallbladder and liver were retracted superiorly.
There were some adhesions involving the inferior surface of the
gallbladder involving the greater omentum that were gently teased
away.  The infundibulum of the gallbladder was grasped and retracted
laterally.  The peritoneum was stripped away from the gallbladder and
cholecystoduodenal ligament.  There were also some inflammatory
changes in this area.  The cystic duct was identified as it exited the
gallbladder and freed up for a few millimeters.  A clip was placed
across the cystic duct adjacent to the gallbladder.  An opening was
made in the cystic duct with microscissors.  There were several small
stone particles extracted from the cystic duct.  Once there was free
flow of bile, cholangiogram catheter was inserted under direct
visualization through a separate trocar in the right upper quadrant.
The cholangiogram catheter was inserted into the cystic duct and the
duct was occluded around the catheter using 1 clip.  Cholangiograms
were performed with fluoroscopy.  There were some small filling
defects in the distal common bile duct.  The common bile duct and the
hepatic ducts were mildly dilated.  There was very minimal flow of dye
into the duodenum.  There appeared to be at least a few stones in the
distal common bile duct that were obstructing in nature.  I attempted
to flush these through the ampulla without success.  The cholangiogram
catheter was then removed.  The cystic duct was occluded with 2 clips
to not compromise the cystic duct-common bile duct junction.  The
cystic duct was transected.  There were 2 branches of the cystic
artery and each were dissected free adjacent to the gallbladder,
doubly clipped and divided.  Remaining peritoneal attachments off the
inferior surface of the gallbladder were gently teased away.
Electrocautery was used to dissect the gallbladder from the liver bed
once sufficient distance was obtained away from the porta hepatis.
Prior to division of the final peritoneal attachments, the liver bed
was irrigated with saline.  Hemostasis was strict.  All saline was
suctioned from the abdomen.  The final peritoneal attachments were
divided.  The laparoscope with attached camera was placed through the
epigastric cannula.  An EndoCatch bag was placed through the umbilical
cannula and the gallbladder placed into the bag.  The bag, contents
and cannula were all retrieved through the incision.  The Hasson
cannula was reinserted and pneumoperitoneum was reestablished.  The
appendix was again inspected.  I elected to perform a laparoscopic
appendectomy as there was some dilatation of the mid portion of the
appendix.  An opening was made between the mesoappendix and the
appendix adjacent to the cecum.  The appendix was divided at the cecum
using the endoscopic GIA stapling device with 3.5 mm staples.  The
mesoappendix was divided using the endoscopic GIA stapling device with
2.5 mm staples.  The appendix was grasped with forceps through the
umbilical clamp and the cannula, forceps and appendix all removed.
The specimen was submitted for pathology.  The Hasson cannula was
again reinserted and pneumoperitoneum was reestablished.  The abdomen
was again inspected.  Both staple lines were visualized.  Hemostasis
was strict.  No other abnormalities or injuries were noted.  Remaining
cannulas were removed under direct visualization.  The
pneumoperitoneum was decompressed.  The fascial incision at the
umbilicus was closed using interrupted sutures of 0 Vicryl.
Subcutaneous tissues were irrigated with saline.  All skin incisions
were closed using subcuticular sutures of 4-0 Vicryl.  Dermabond was
applied.  At the completion of the procedure, all sponge, needle and
instrument counts were correct.  Estimated blood loss was 20 mL.  The
patient tolerated the procedure well and was transported to the PACU
in stable condition.

Here is what I have:
47563-574.71
44970-59,51-543.9

Thanks a lot!


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## FTessaBartels (Jul 6, 2011)

*44955*

I would consider the appendectomy as "when done for indicated purpose at time of other major procedure."  The surgeon clearly states the reasons why s/he felt the appendix needed to be removed (i.e. it was not just incidental), so I would use the add-on code CPT 44955.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## cmartin (Jul 11, 2011)

I think you were right the first time - 44970 is correct for a lap appy for cause during another laparoscopic procedure.  See NCCI narratives.  Since the narratives are only updated once a year, they're still Version 16.3.  Page VI-9, or F.5. under Laparoscopy in the 40000's rules.


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