# Help with this staged colectomy and terminal ileostomy



## Patricia Donegan (Jan 8, 2012)

Not sure how to code this procedure. Patient had an open exploratory lap in first surgery with a partial colectomy, but the anastomosis and ileostomies were not done so patient could be
further resuscitated and worked up and stabilized.....

Diagnosis of pneumatosis intestinalis of the terminal ileum with multiple other problems heart dis, a-fib, pacemaker, CHF, chronic alcoholism, PVD . Pt was found down in his bathroom unknown period of time.  Was admitted thru ER hypotensive acidotic, abdm pain, reuscitated 2 units PRBCs, lines placed. Multiple abrasions, decubitus ulcers , CT suggested post traumatic bowel perforation.  , rib fx, . bilat pubic fx, sacrum fx, etc.  Pt scheduled for  abdominal  exploration with need for possible resection & ostomies. 

I was thinking code 44140 for the first procedure, but the anastomosis wasnt done, so should I just use a 52 modifier for the reduced portion of the procedure.....or just bill an exploratory lap....but I dont think that would be correct since there was a partial colectomy done.  But cant find a code without anastomosis or ostomies, so mod 52 might work.   Then for the second surgery 2 days later....where the surgeon resects more ileum ....and does an ileostomy....thought about 44160 with a 58 staged modifier....but he decides against the ileocolostomy and does only a terminal ileostomy...so would it be 44144-58...or 44160 with again a reduced modifier 52......But honestly, he did part of the  partial colectomy 2 days prior....dont want to count it twice....so confusing.....Sorry Im new to general surgery, have always done cardiothoracic,  so I'm truly confused by the 2 procedures...Ive listed the main sections of the op reports below for any help ....PLEASE....

First Procedure Performed:
 A midline incision was made from 6cm above umbilicus to the pubis.  Abd. cavity was entered .cavity .was explored.  We found the terminal ileum and mostly the cecum and ascending . colon has evidence of gross pneumatosis ...After inspection of whole abdom.cavity no pathology could be seen except at the terminal ileum, cecum, and ascending colon .  Terminal ileum was mobilized...decision was made to  remove the bowel with pneumatosos.  Mesentery of the terminal ileum was divided about 15cm proximal to the ileocecal valve at the level of a healthy bowel.  Mesentry was opened.  GIA was fired across the small bowel.  Then we mobilized the hepatic flexure.  We chose a spot in the junction of ascending transverse colon where the bowel was looking healthy to divide the mesentery.  Peritoneum was marked over mesocolon.  LigaSure was used to divide rest of mesentery.  GIA stapler was fired...Specimen was passed over the table.  Abdominal cavity was irrigated with warm normal saline.  Due to the fact that the pt was on some vasopressors at the end of the procedure we decided to take a second look operation in 24 to 48 hours after resuscitating him more and stabilizing him, so we decided not to connect the ileum to the colon. The free ends of the transverse colon  and terminal ileum were dropped in the abdomen and the skin was closed  in a continuous 2-0 prolene suture....
 **** so I thought code 44140-52......



Two days later....

Procedure:
Re-exploration of abdomen, resection of terminal ileum about 20cm, terminal ileostomy , abdominal washout, closure of abdomen.  

The abdominal cavity was explored.  The colon was inspected from the transverse colon all the way to the rectum was looking viable.  Small bowel inspected.  Terminal ileum was about 10 cm looking congested.....Decision was made to remove the piece of small bowel that was congested proximal to the staples from the previous exploration.  A decision was made not to proceed with ileocolostomy for chance of leaking, making patients situation worse.  We decided to do a terminal ileostomy which at some point could be reversed.  As far the transverse colon and in order not to give him another wound with another ostomy, decided to reinforce the stump with running 4-0 prolene suture in order to cover the stapleline.  The stump was tacked in the right side of the abdominal wall below the incision at the upper part of the incision noted to be found later for possible reconstruction....
The abdominal cavity was washed with couple liters of warm normal saline....Ostomy incision was performed in the rt lower quadrant in the usual position at the level of rectus muscle.  The cruciate incision was was performed...A size of 2 fingers was performed under direct vision using bovie cautery.......about 7cm small bowel were brought above the skin level without any difficulty.....the bowel was tacked with posterior abdominal wall . The midline fascia was closed under direct vision....The staple line of the ileostomy was removed and teh ileostomy was matured in the usual fashion....It was pink and viable....Pt transferred to ICU....
**** could this be 44160-52-58..... HELP


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## Lujanwj (Jan 9, 2012)

Possible codes:
44160-52 (-52 for no ileocolostomy)

2nd trip to OR: 
44125-58 - Ileostomy
44604-58 - Reinforce the stump


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## Patricia Donegan (Jan 9, 2012)

thank you for your help


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