# Graham Patch Repair without suture of perforated duodenal ulcer



## purdyboy (Dec 28, 2016)

I have been trying to find this answer for two months and have been unsuccessful - I hope that someone on this forum can help me. It does not appear that the physician sutured the ulcer before he placed the graham patch. I am including the pertinent notes:  The perforation was at the cranial aspect of the first portion of the duodenal past the pylorus. The inflammatory response had involved the neck of the gallbladder as well as the infundibulum. I needed to dissect some of the space around the perforated ulcer in order to do a Graham patch repair. In doing this dissection, they cystic duct was identified because of its close proximity to the ulcer perforation. There were palpable stones in the gallbladder. At this point, with the gallbladder inflammation as well as the location of the perforation of the ulcer, I felt that future need for cholecystectomy would be extraordinarily difficult after duodenal ulcer perforation and repair, so I performed a cholecystectomy. I isolated the cystic duct and cystic artery. Clips were placed on the cystic duct proximal and distal and it was transected. The artery was clipped and cut in the same fashion. Dissection of the gallbladder was then carried out with electrocautery, and it was removed intact and sent for specimen. At this point, more dissection could be carried out on the superior aspect of the first portion of the duodenal into the pylorus and antrum of the stomach. At this point, I needed to get the NG tube passed into the stomach for decompression...There was somewhat deep ulcer at the GE junction; however, appeared noninflamed and nonperforated...I scrubbed back into the abdominal surgery and secured the NG tube in the stomach with my hand as the anesthesiologist secured the NG tube to the patient's nose. With the EGD scope in the NG tube, we aspirated 1300 mL of gastric content...At this point, I dissected free a piece of the omentum from the transverse colon. It was well vascularized, I rotated the omentum up over the duodenum. I used 3-0 silk sutures to imbricate the omental patch over top of the duodenal ulcer. After the silk sutures were placed and secured, ulcer was well patched...

Nowhere in the note does it state that the gastric ulcer was sutured closed before placing the omental flap. I am being told that I should code 43840, 47600, 49905 and 43241 for these procedures. My argument continues to be that the doctor didn't suture the gastric ulcer, he simply placed an omental flap, which is 49905, but that is an add on code. Can someone please give me some guidance on this? If the codes that I have been told to use are correct can someone please explain? Was the ulcer repaired when the cholecystectomy was done?

Thank you so much for any help you can provide.
Andrea


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## blara (Dec 28, 2016)

The duodenal ulcer was repaired by graham patch repair- where a piece of the omentum was sutured on top of the duodenal ulcer as is indicated in the portion of the report stating "I used 3-0 silk sutures to imbricate the omental patch over top of the duodenal ulcer. After the _silk sutures_ were placed and secured..". To me, those codes you are indecisive about look correct. Hope that helps.


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## purdyboy (Dec 29, 2016)

But it doesn't look like they actually did a suture of the ulcer - that is what is confusing me because 43840 is for a suture of the ulcer; I cannot find in the note where there was a suture of the ulcer. If there is no suture of the ulcer then I wouldn't think I could charge out the 43840. 49905 includes suture of omentum to defect area. Am I missing the suture of the gastric ulcer?


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## blara (Dec 29, 2016)

The perforation of the ulcer was sutured when the graham patch repair was done
Code 43840_ Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury_ would need to be coded along with code 49905 _Omental flap, intrabdominal_. As you noted before, code 49905 is an add on code. Code 43840 describes the primary procedure that was done while add on code 49905 describes how it was done. 
The perforated duodenal ulcer was sutured with a piece of the patient's omentum. This was how the perforation was repaired.

Then the other codes
47600- cholecystectomy. Correct since the gallbladder was removed
43241-esophagostroduodenoscopy with insertion of intraluminal tube or catheter. I'm assuming this is correct to account for the  the EGD tube within the nasogastic tube.


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