# lap mobiliz of splenic flex with open colectomy



## CCARRIE (Nov 15, 2011)

Hello i have a physician who did a lap mobilization of splenic flexure with open left colectomy. 

Procedure details:  With informed consent obtained the patient was brought to the operative room and placed on the table in supine position with adequate padding of all pressure pints and compression devices on both lower extremities. After the successful induction of general anesthesia, the abdomen was prepped and draped sterilely. Under direct laparoscopic visualization and additional local anesthetic,a 5mm Optiview trocar was inserted in the central abdomen ina prior paramedian incision. A pneumoperitoneum was created. Visual exploration revealed some omental adhesions in the right upper quadrant and along the falciform ligament and evidence of intraperitoneal spread of her colonoscopic tattooing, but no pathology was encountered. Two additional trocars were insterted in the patient's old incision. Some of the upper midline incisions were lysed with the Harmonic. The descending colon was identified and reflected medially and the proximal and distal tattoo sites were identified. The colon was the mobilzed by incising the white line of Todt extending cephalad to the splenic flexure where the colon and omentum were noted to be adherent to the undersurface of the spleen. This was freed which did result in a small capsular tear of the tip of the spleen which made hemostatic with the Harmonic. This mobiliztion continued for a significant distance proximally along the transvere colon and then contnued back antegrade elevating the tissues off of the retroperitoneum and down distally to include mobilization of the proximal sigmoid colon. It was somewhat difficult to identify the plane of the mesentery from the retroperitoneum. With the colon largely mobilized, and area of bleeding was encountered in the left lower quadrant and this area was controlled with a grasper and the case converted at this time to the planned open colectomy.

The pneumoperitoneum was released and the trocars were removed. A standard mid abdominal medline incision was made and cautery was used to dissect through subcutaneous tissue, the fascia and into the peritoneal cavity. The small bowel was reflected to the patient's right to allow exposure of the area of interest in the left lower quadrant and the retroperitoneum. Concern was for an ureteral injury. A structure felt to represent the left ureter, coursing in a cephalocaudad direction in the retroperitoneum, was identified. However, it did not move in typical ureter fasion and thus prior to ligating permanently the bleeding vesse, attempts to confirm patency of the ureters were made which included injection of methylene blue which did not help due to low urine output and thus an intraoperative ivp was obtained which eventually confirmed intact left and right ureters and this structure was ligated. Actually at the conclusion of the ivp, the structure that was felt to represent the ureter did begin to contract and move in typical ureteral fashion.

Accordingly, the procedure was continued with completion the mobilization of the colon from the retroperitoneum. Margins of resction were identified to be at least 5cm from the proximal and distal markings and this roughly correspinded to the splenic flexure and the descending sigmoid junction. At both of these levels the colon was transected with a GIA and the mesentery was then removed in a wedge-shaped fashion down to its base controlling vessels, ties and ligatures appropriately. The specimen was removed. The ends were then brought in side-by-side and an anastomosis created.

The colectomy would be coded 44140 but the mobilization would be 44213 but per ama notes this code is used in conjunction with 44204-44208. Should i use 44139?

thanks


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## oyboutj (Feb 4, 2016)

*44140 and 44213?*

There are 3 options:

1) Report the lap splenic mobilization with the open colectomy code - 44140 + 44213
-This will certainly get 44213 denied since the open colectomy 44140 is not one of the listed primary codes for 44123

2) Switch the lap splenic mobilzation code to an open mobilization code  - 44740 + 44139
-This presents an obvious audit issue, since on review the documentation would not support the open mobilization code 44139

3) Use an unlisted code for the lap splenic mobilization  - 44140 + 44238 and specify the "Laparoscopic mobilization of the splenic flexure at the time of open colectomy is unlisted procedure.  (And then price base on 44213)

My opinion is that option 3 is the only viable coding option, but I am open to other suggestions.

Scott Freathy, MD, CPC


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