# Intra-Abdominal Abscess and Necrotic Anterior Abdomen



## tabbsmith (Nov 10, 2011)

I need help with coding this Op Report:

I opened the anterior fascia and a large amount of purulent fluid was encountered.  We cultured this and removed the rest of the fluid.  I then opened the posterior fascia.  The small bowell was adherent to the intra-abdominal wall.  This was taken down bluntly and there were wispy adhesions.
I placed the Bookwalter for visualization.  I ran the small bowel beginning at the ligament of Treitz. There was adhesions that were taken down sequentially to visualize the entire bowel.  In the mid jejunum, the bowel was stuck to the right abdominal wall, near where the abscess was.  This was taken down with Metzenbaum scissors.  There was a small enterotomy there, which drained into the abscess cavity.
We removed all the fluid from the abscess cavity.  I continued to run the small bowel.  There was only one injury noted.  I did create one serosal tear while freeing the small bowel from the abdominal wall.  This was oversewn with interrupted3-0 silk lembert sutures.  I inspected the colon in its entirety.  There were no injured noted.  there was some fluid down in the pelvis, but it did not appear infected.
We located the portion of the bowel that has hole in it.  I made a mesenteric defect proximal and distal to this.  The bowel was divided with a blue load GIA staplers.  I approximated the small bowel with 3-0 sutures.  I then divided the mesentery between hemostats and tied this off with 2-0 silk.  I then made an enterotomy in both the proximal and distal limb.  I placed the 55 blue load GIA stapler.  The small bowel was anastomosed in a side to side fashion.  I removed the stapler and inspected the staple line.  There was no bleeding.
I addressed the abscess above the liver.  I opened the abscess cavity completely.  There was succus and there is several pieces of particular matter.  We irrigated this out aggressively.  In mobilizing the liver, a small tear in the left lobe was created.  This was cauterized for good hemostatsis.  The liver was adhesed to the anterior wall of the stomach.  We bluntly dissected that.  There was no apparent infection in the left upper quadrant.  We irrigated the abdomen with approximately 6L of saline until it returned clear.  Re-addressing the anterior abdominal wall, part of the rectus sheath was necrotic bilateraly (230 sq cm )  this was sharply removed.  I also removed more of the soft tissued that was necotric.  This was unable to be closed as the fascia was not very health and there is a large defect in the lower abdomen.

Here are codes that I have come up with:
44005 -- Adhesions
44120 -- Small stomach resection with anastomosis
44604 -- Serosal Tears
47350 -- Liver Tear
47010 -- Liver Abscess

Please Advise  //  I know there are still codes that I am missing especially removing the Necrotic Skin


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## surgonc87 (Nov 11, 2011)

This is what I would code, no more no less. If the surgeon documents time spend on LOA, you can add a mod 22 on primary CPT. Also you cannot code for iatrogenic injuries. Also, you should refer to NCCI documents and CCI bundling edits.

49020-m-22
44120
11005

MS


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## tabbsmith (Nov 15, 2011)

thanks for your help with the coding -- this is very helpful to me.


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