# Laparoscopic appendectomy.  Placement of drain.



## sara0014 (Sep 11, 2013)

*Needing assistance with capturing all of the CPT codes. Fair new at coding general surgery.*

PREOPERATIVE DIAGNOSIS:  Appendicitis.   

POSTOPERATIVE DIAGNOSIS:  Perforative appendicitis with periappendiceal abscess.  

PROCEDURE:  Laparoscopic appendectomy.  Placement of drain.  

ANESTHESIA:  General oral airway.  

This young lady presented to the emergency department early this morning with right sided abdominal pain, which has been intermittent throughout the week but worsened very substantially in the last 24 hours.  No prior surgical history.  No allergies.  She had peritoneal signs in her right lower quadrant on physical exam.  We ordered a white count and it was 18,000.  I talked with the patient and her mom and dad and highly recommended laparoscopy with a presumed diagnosis of appendicitis.  We discussed complicated versus routine appendicitis, the possibility of her going home later today.  

PROCEDURE:  She was given cefoxitin 2 gm preoperatively and her umbilicus was marked by me while she was in the ER, prior to taking her to the operating room.  General oral airway anesthetic was given.  Chloraprep and appropriate draping.  We used a three-port technique, right mid abdominal, five port, two in the midline.  Initial drip test was good and her initial pressure was 2.  She has a walled off phlegmon.  The lateral most aspect of the ileomesentary is containing the abscess.  Her appendix is very foreshortened and very thickened and very difficult to fracture off the right lateral abdominal wall.  However it was not that difficult to do, so we did not merely drain her, but we pursued formal appendectomy by carefully and slowly using suction irrigation and blunt dissection and eventually isolated her mesoappendix.  This is delineated in many photos.  The mesoappendix was taken in three separated staple lines.  We then transected the appendix, delivered it in an Endo bag and then went back and re-identified the stump of the appendix and dissected out maybe another centimeter of the appendiceal wall flush to the cecum and then shot our final staple line across the cecum itself and thus two specimens were sent and one is a smaller fragment which contains nice soft cecal wall.  A fecalith that had been expressed from the appendix as I was manipulating it, was removed from the peritoneal cavity.  There was only one small bit of fecal contamination.  The abscess was completely suctioned out and her right gutter pelvis and suprahepatic space all cleared completely with saline.  There was no bleeding.  We inspected all of the staple lines repeatedly.  We then placed a Jackson-Pratt through the five port site on the right mid abdomen, placed it lateral to the cecum and down into the pelvis.  That was anchored at the body wall with an 0 Vicryl.  More Marcaine into all three wounds.  Fascia was visually identified and both 12 ports were closed with interrupted 0 Vicryl. Those wounds were closed with 4-0 Vicryl. EBL:  20 mL or less.  
COMPLICATIONS:  None.  

She will need to be an inpatient for appropriate therapeutic IV antibiotics.


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## cynthiabrown (Sep 11, 2013)

Just 44970  no charge for drain


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## FTessaBartels (Sep 12, 2013)

*Add 22 modifier to 44970*

Since there was documented difficulty, plus peritonitis, I would add modifier 22 to 44970. 

By the way ... there is a separate OPEN code for appendectomy, for ruptured appendix  with abcess or generalized peritonitis, with a much higher RVU value that a straightforward open appendectomy.

But there is only ONE Laparoscopic appy code ... with no mention of the complication of ruptured appendix, abscess and/or peritonitis.  Go figure ....


Hope that helps.

F Tessa Bartels, CPC, CEMC


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