# Exp Lap abdomen, freeing bowel adhesion



## bill2doc (Apr 11, 2013)

EXPLORATORY OF ABDOMEN
FREEING BOWEL ADHESION ENTEROLYSIS 

Can I only use 49000 or 44005 ??  Can anyone help with CPT(s). Thanks

A generous midline incision was made through scar and carried through the subcutaneous tissue to the fascia.  The tissue was quite edematous at every layer. The fascia was incised and abdomen opened.  No bloody or purulent fluid noted and no obvious sequalae of an intra-abdominal accident.  The bowel was grossly edematous throughout and was massed together with adhesions and reactionary inflammatory tissue.  The bowel was sharply separated from the abdominal wall with scissors and the Bookwalther retractor was placed.  Exploration began in the left lower quadrant.  The colon was surgically absent.  The loops of bowel were tediously dissected from one another, taking care to avoid serosal tears.  In the pelvis, there was a whitish exudate noted associated with what was later noted to be the rectal stump.  This fluid was sent off as a culture.  The stump itself was examined.  The suture line appeared to have a small amount of inflammatory response and had adhered to some fatty tissue in the abdominal wall.  Even though the reaction was small, the decision was made to resect it.  A curved linear cutting stapler was then use to divide the proximal rectal stump.  The suture line was then passed off the field as a specimen.  The bladder was mildly distended.  The remainder of the bowel was then examined after the many adhesions were lysed.  The entire bowel appeared edematous, and was thickened yet friable.  The bowel was then run from the ligament of trietz to the ileostomy.  No obstructive segment was identified.  The diameter of the bowel was reasonably consistent throughout its length.  Two firm nodules were noted at the remainder of the colonic mesentery.  One was close to previous sutures, and these were resected and passed off the field as a specimen.  The stomach was examined and the NG tube was noted to be in good position.  The liver was then examined.  Previous CT scans had noted a mass within the liver, but this could not be palpated and no nodularity on the liver was noted.  A capsular tear was noted during this examination, and hemostasis was maintained with the argon beam coagulator.  There was at this point no evidence of a discrete source of infection intraabdominally.  The inflammatory reaction appeared to be a secondary response..  The bowel was run once more from duodenum to ileostomy and no lesions were found.  Underneath the edema, the bowel appeared pink and viable.  As plans were made to close the abdomen, the bladder appeared to be larger than previous, to the point of hindering closure.  Of note, the urine output was minimal before and during the case.  The foley balloon was not able to be palpated.  The foley was then exchanged in a sterile manner under the drapes.  The bladder then decompressed.  The fluid had fibrinous material and some small clots within it.  The urine was sent as a specimen.  The abdominal wound was then closed and the skin closed with staples.   The midline wound was then cleaned and dressed.  The ileostomy appliance was then placed.


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## hcg (Apr 16, 2013)

bill2doc said:


> EXPLORATORY OF ABDOMEN
> FREEING BOWEL ADHESION ENTEROLYSIS
> 
> Can I only use 49000 or 44005 ??  Can anyone help with CPT(s). Thanks
> ...





I would go for 44005 since it is enterolysis. And you cannot use both codes as 49000 is bundled into 44005. Per CCI 49000 is a component of 44005 and cannot be billed using a modifier


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## margaretl (Apr 17, 2013)

you have a couple nodules of the colonic mesentery which were excised.  Get the sizes documented and code that (i.e 49203)


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