# Pelvic Exoneration - I'm hoping someone can



## Jarts (May 18, 2009)

Good Day All!
I'm hoping someone can help me out with this surgery. I am having much difficulty coding it. Any and all input is appreciated.

PREOP DX: Diverticulosis.
POST OP DX: Metastic adenocarcinoma.

PROCEDURE PERFORMED:
1. Diagnostic laparoscopy.
2. Pelvic exoneration.
3. Partial colon resection.
4. Ileocecal resection.
5. Mobilization of splenic flexure.
6. Omentectomy.

PROCEDURE IN DETAIL: Using the open Hasson technique, a supraumbilical 12mm port was placed. The abdomen was then insufflated to 15 mmHg with CO2, and the 5mm right lateral port was also placed. We then placed the patient in Trendelenburg position and explored the left lower quadrant where there appeared to be a diverticulosis and/or inflammatory findings in the left pelvic side wall. 
Attempt was made to remove this. It became fairly clear that we would not be able to do it laparoscopically especially when we looked down into the pelvis and there appeared to be some metastatic studding of the peritoneum down into the lower pelvis. There was also some fluid in the pelvis which was sent for cytology and culture. At that point, decision was made to proceed with an open procedure.

The patient was then placed in supine position. Midline incision was made. Bookwalter retractor was put into place. The small bowel and contents was packed up into the upper abdomen. The abdomen was then explored with the findings of a large mass in the ileocecal region as well as the splenic flexure. This was also consistent with the mass in the left lower quadrant. Meticulous dissection was then required to remove the mass from the left pelvic side wall. Ultimately, we were able to identify and remove the mass in its entirety. This was carried down into the lower pelvis. The left ureter and right ureter were then clearly identified and followed from their path in the upper abdomen down to their insertion into the pelvic side wall, keeping them out of harm's way. 

The dissection was then carried down into the pelvis into the low rectal mid-rectal region where the bowel was then amputated, and a pursestring of 2-0 Prolene was placed, and a 28mm anvil was placed in the mid rectum for future anastomosis. The bowel was then brought up and amputated in the mid sigmoid where it appeared to be free of any significant other abnormalities. We then began to mobilize the splenic flexure and identified the previously identified significant splenic flexure lesion. Splenic flexure was then completely mobilized as week, and then the bowel was amputated at the distal transverse colon, and the splenic flexure colon was removed from the operative field. The proximal bowel was then mobilized and brought down easily to the pelvis where an end-to-side Baker anastomosis was performed with a 28mm EEA stapler. At that point, we then proceeded to explore the remainder of the abdomen and clearly identified the ileocecal mass as well. We did consider doing a diverting ileostomy, but it appeared that everything would come together nicely without any signs of any tension or lack of vascular supply. Thus the decision was made to proceed with the ileocolonic resection as well. The mesentery was divided between Pean clamps. Two ends of the bowel were then placed side to side at the terminal ileum and ascending colon, and a functional end-to-end stapled anastomosis was performed wit the GIA-75 stapler. The mesentery was closed interrupted 3-0 silks, and the specimen was removed from the table. 

The omentum was then taken down from its attachments and removed from the abdomen. The abdomen was then irrigated with copious amounts of normal saline. The small bowel was ran its entire length, looking for any signs of any other metastatic disease. The metastatic disease greater than a centimenter. No other foci of tumor was identified. The abdomen was free of any significant signs of bleeding, other than some mild ooze from the open retroperitoneum as pelvic structures were completely skeletonized from the bifurcation of the aorta down into the pelvis, but there was no active bleeding. The abdomen was irrigated with copious amounts of normal saline and suctioned clear. The anastomosis was inspected again, both the pelvic anastomosis and the ileocolonic anastomosis. The upper quadrants were inspected for any problems with hemostatsis, which there were none and the decision was made to close.


ADDITIONAL INFORMATION FROM THE DC SUMM:

*
The Discharge summary reads as follows:*
HOSPITAL COURSE: Patient was admitted with a presumed dx of diverticulosis. She was taken to the operating room, where a diagnostic laparoscopy revealed that she had peritoneal studding, consistent with possible intraabdominal carcinoma. Thus, the surgery was converted to an open procedure. *She then underwent an extensive debulking of ovarian cancer, consisting of a pelvic exoneration, a left oophorectomy, and bowel resection x 3 as well as omentectomy. *


Having a tough time with this one,
Julie


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## Jarts (Jun 15, 2009)

We're thinking:
dx: 183.0, 562.10
CPT: 
58952 with mod 52 due to only left oophorectomy
44145-51
44140-51
44139

Any input?


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## FTessaBartels (Jun 15, 2009)

*Not my area of expertise*

*NOT* my area of expertise ... BUT ...

I don't see *any *mention of oophorectomy in the body of this op note.
Doctor needs to amend op report if he performed this.

Could this be 49203-49205? (Would need size of tumor.)

Also I believe 44140 and 44145 bundle; I'd use 44145 only. 

I don't think you can use the info in the DC summary to code the op note. 

Hope this doesn't further confuse.

F Tessa Bartels, CPC, CEMC


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## Jarts (Jun 15, 2009)

Thanks for responding! 
If doc ammended the op note to include the left oophorectomy, would you then go with 58952?


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## FTessaBartels (Jun 15, 2009)

*Ask the physician*

I'd ask the physician which code best describes what s/he did.

Was this 4920x (depends on size of tumor, or if multiple tumors, size of largest mass - NEED *amendment* for size of mass)

-OR-

Was this 58952 (would need *amendment* for oophorectomy and *-52 mod *because not bilateral)

Both these codes would allow you to also use 44145(51) and 44139.

Based on what's currently documented I think I would be leaning towards 4920x. (Oophorectomy would not be separately coded ... it bundles into this code.)

Just my opinion ... and I am *NOT *an expert in this field.

F Tessa Bartels, CPC, CEMC


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## Jarts (Jun 15, 2009)

Thank you so much!! I'll talk to my doc for clarification.


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