# Open Small Bowel Resection due to Enterotomy during Colostomy takedown



## mgord (Sep 10, 2014)

The surgeon performed a Lap Colostomy Takedown, Lap Lysis of Adhesions, Lap mobilization of splenic flexure and open small bowel resection. 
I only charged for the 44227 for Lap Closure of Enterostomy. The surgeon wants to also charge 44120 Open small bowel resection, which is bundled but he states this should be a billable service and to use a -59. 
I'm a little unsure about using the open code since he never converted the procedure to open. 

Also can anyone clarify if an enterotomy is caused during a procedure due to a huge mass of adhesions or a SBR has to be performed due to an enterotomy are these billable services?? I didnt think so but he seems to disagree. Please help or point me in the direction of documentation that can assist with this. I posted pertinent parts of the op note (I cant cut and paste). Thanks so much!!

...We freed the small bowel from the pelvis. There were a couple loops that were densely adherent and we did end up with an enterotomy. Once that was freed and elevated, we closed that with an endoscopic GI staple load with plans to resect that segment later......

...We grasped that segment of small bowel and flattened up the patient and gas is expelled. We then made an elliptical incision around the stoma, which was dissected from the subcutaneous tissue, fascia musculature and then brought out. We identified the point, dissected the mesenterium and transecting the bowel. At this point, the ostomy was removed and sent for pathologic evaluation. It easily dilated with a 29, maybe a little bit snug; therefore, we used a 28 EEA. We placed 2 prolene purse-string in the open end of the colon. We placed a Seamguard on the anvil, placed in the colon then secured the purse-string and the colon was then reduced into the abdominal cavity. We then brought out the segment of small bowel in question. It did appear pretty ratty from the adhesion along with the staple line. We elected to resect this. We took the mesentery down with the Ligasure. We divided the small bowel proximal and distal to the segment, removed that small bowel and sent out for pathologic evaluation. We then secured the bowel together with silk stay sutures. We performed a routine staple anastomosis. There was 1 bleeding point on inspection, the staple line that was secured with the silk suture and the lumen of the bowel. We then closed the enterotomy with a TA stapling device. Dirty instruments were removed and the gloves were then changed. The mesentery was closed with multiple #1 figure-of-eight silk sutures, and we then reduced the small bowel back into the abdomen. The fascia of the ostomy site was closed on multiple #1 figure-of-eight PDS sutures and moist gauze was placed in the open ostomy site. The pneumoperitoneum was reestablished......

He then anastomosed the colon to the rectal stump.


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## bigredcag (Sep 16, 2014)

assuming in the practice "LAP" means laparoscopy and not lapartomy.
The 44227 includes "resection and anasamosis" so you cannot bill seperatly with the 44120. IF the dr is just pulling the intestines out of the Lap site to cut and sew and did not do a formal open you cannot bill open. but if he started lap then went open, Everything will be billed as an open procedure(44626) with an additional dx v64.41 Lap converted to open.

As for the the enterotomy caused by LOA well that is tricky.  On this case the intent of the surgery was to remove the colostomy o you would bill the 44227.
now if the intent of the surgery was simply to Lysis of Adhesions and an enterotomy accidently done we would not bill for the repair, you broke it you fix it at no charge to the patient.. that is how we look at it.  see below.
good luck, hope this makes sense

the NCCI policy manual chapter 6:
If an iatrogenic laceration/perforation of the small or
large intestine occurs during the course of another procedure,
repair of the laceration/perforation is not separately
reportable. Treatment of an iatrogenic complication of surgery
such as an intestinal laceration/perforation is not a separately
reportable service. For example CPT codes describing suture of
the small intestine (CPT codes 44602, 44603) or suture of large
intestine (CPT codes 44604, 44605) should not be reported for
repair of an intestinal laceration/perforation during an
enterectomy, colectomy, gastrectromy, pancreatectomy,
hysterectomy, or oophorectomy procedure.


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