# Lap colostomy reversal, lysis of adhesions, flex sig procedure.



## maljdcpc (Mar 28, 2016)

Need help coding the following procedure. Not sure if coding this right so any input/corrections would be greatly appreciated. Not sure if I could add 22 modifier on 44227 for lysis of adhesions? I didn't get any NCCI edits for flex sig 45330- however, is it right to code it in this case?  

A time-out was performed. An incision was made around the colostomy.           
Dissection continued down to the fascia. The fascia was circumferentially      
mobilized until the significant portion of the left colon could be mobilized   
through the wound. The colostomy remnant was resected. A pursestring suture    
was placed around the cut end of colon, the anvil 29 EEA stapler was placed    
in anticipation of an end-end anastomosis. There was occasional                
diverticulosis, that was seen, which had not been seen on the colonoscopy.     

The bowel was placed back into the abdomen and a Gelpoint wound protector      
was placed. The top of the Gelpoint was also inserted. Pneumoperitoneum was    
easily achieved. There were significant adhesions of omentum to the anterior   
abdominal wall. A 5 mm port was placed in the left lower quadrant. These       
adhesions were taken down using the Harmonic scalpel.                          

A 10 mm port was placed in the right lower quadrant, a 5 mm port was placed    
in the right upper quadrant. The left colon could easily be seen. It was       
retracted medially. The white line of Toldt was incised. The entire left       
colon and splenic flexure were carefully mobilized. There is a small           
capsular tear in the spleen that was easily controlled with fibrillar.         

Dissection was now continued in a retroperitoneal fashion up under the         
inferior mesenteric artery. This was circumferentially cleaned, divided with   
an Echelon load with a white load. In addition, the IMV was also identified    
and circumferentially clean and also divided with an Echelon load with a       
white load. The vessels had to be taken in order to ensure adequate length     
for reach for the anastomosis of the left colon.                               

With this accomplished, attention was now paid to the pelvis. The Hartmann     
stump could easily be seen. The small bowel was lifted out of the pelvis.      
The presacral space was entered. Dissection was continued to rest for short    
distance until soft healthy, pliable area of rectum was identified just        
above the peritoneal reflection. The mesorectum in this region was divided     
with Harmonic scalpel. The rectum was divided with an Echelon load with a      
gold load. The Hartmanns pouch remnant was then brought out through the        
left lower quadrant ostomy site through the wound protector and sent to        
pathology along with the colostomy remnant to Pathology for routine            
processing.                                                                    

A 29 EEA stapler was now inserted into the rectum until the end of the         
stapler was flushed with the end of staple line. The trocars advanced. The     
anvil of the proximal bowel was engaged onto the trocar. After ensuring        
correct orientation, the stapler was closed, fired and removed, both donuts    
were full-thickness, circumferential and completely intact. It was sent for    
pathology for routine processing.                                              

The proximal bowel was clamped off, the pelvis was filled with fluid. I        
performed flexible sigmoidoscopy. There was no evidence of leak from the       
anastomosis. The scope was now removed. The anastomosis appeared to be at      
approximately 10 cm. There was no bleeding.  Dr. Sherman then rescrubbed       
into the case. A fascial suture made of 0 Vicryl was placed in the right       
lower quadrant 10 mm port using a laparoscopic suture passer. A 19-French      
drain was placed in the pelvis adjacent to the anastomosis and brought out     
through this right lower quadrant wound. In addition, a 19-French JP was       
placed in the left upper quadrant adjacent to the spleen. Since this, the      
patient will be having anticoagulation to ensure no bleeding from the          
splenic capsular tear and to ensure no pancreatitis as well. Both drains       
were secured to the skin using Vicryl suture.                                  

The abdomen was now desufflated. All ports and the wound protector were        
removed. The fascia at the umbilical port site was closed with a               
figure-of-eight 0 Vicryl suture. The fascia of the left lower quadrant         
colostomy site was closed with 0 Vicryl running from both ends in a vertical   
fashion and tied in the middle. All wounds were carefully cleaned and          
anesthetized with 0.5 percent Marcaine solution. A pursestring suture was      
placed in the skin of the colostomy to cinch it down and the central portion   
was packed with saline-soaked gauze and covered with 4 x 4s. The umbilical     
wound was covered with benzoin and Steri-Strips. Drain sponges were placed     
around the 2 drains. An NG tube had been placed at the beginning of this       
procedure. The patient was now awakened, extubated, and taken to the           
recovery in stable condition having tolerated the procedure well.    

Codes provider used: 44207,44227,44213,44180,45330
I coded as the following: (Please correct/educate me if I am wrong)
44207
44227,59,22
44213
45330


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## CELADYBUG13 (Mar 29, 2016)

I see 44227 only - lap closure of enterostomy, large or small, with resection and anastomosis.  Flex done for leak test - normally not billed - adhesions appeared minimal and no time mentioned in note - 44213 (add on code) can't be billed with 44227.


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