# Small bowel resection with end ileostomy and distal mucous fistula



## hpierce

I can't quite wrap my head around this. 44125-22??? Can you bill for the small bowel decompression? Any advice? Thanks Heather, CPC

DIAGNOSES:
     1.  Chronic small bowel obstruction secondary to diffuse carcinomatosis.
     2.  Diffuse carcinomatosis, developing the entire peritoneum, solid organs on the peritoneal cavity, as well as all of the mesentery and small bowel and omentum.
PROCEDURES:
     1.  Exploratory laparotomy.
     2.  Segmental small bowel resection with end ileostomy and distal mucous fistula.
     3.  Intraoperative open small bowel decompression.
PROCEDURE IN DETAIL:
After obtaining informed consent, the patient was brought to the operating suite and placed in supine position.  General endotracheal anesthesia was administered without complication. Preoperative prophylactic IV antibiotics were administered, and SCDs were placed on bilateral lower extremities.  The patient did receive subcutaneous heparin prior to surgery.  A Foley catheter was placed with the use of standard sterile technique. The patient's abdomen was clipped and prepped with a ChloraPrep solution.  A midline incision was made.  Cautery was used to dissect the subcutaneous tissues down to the level of the fascia.  The fascia was opened along the midline, and the peritoneum opened directly near the level of the umbilicus.  The incision extended superiorly and then inferiorly.  It has been getting down inferiorly and appeared to be quite thickened and somewhat nodular and the fascia was opened for the length and the peritoneum was in place.  This is becoming quite thick and dense.  The abdomen was marked, underlying small bowel was markedly dilated.  There was clear ascitic fluid.  This was suctioned free and sent to Pathology for cytology.  The small bowel was starting being eviscerated, and there was clear nodularity along the bowel and the mesentery.  The scan locations in the peritoneum was palpated.  There was marked carcinomatosis, and some of the multiple small deposits that were coalesced particularly in the right lower quadrant, left lower quadrant, and pelvis.  We can see there is fairly dense omental nodularity as well.  The right lower quadrant had basically narrowed bowel where there was a hard mass that was basically fixed to the right pelvic brim.  The small bowel was eviscerated, was markedly dilated, and chronically thickened. There is no signs of any bowel perforation.  The bowel was run  down through the right lower quadrant, where there was indeed level of obvious chronic blockage.  However, this was felt not to be resectable.  The right colon however was socked in with multiple metastatic deposits and was decompressed and so was the    transverse colon and left colon.  The sigmoid colon was basically plastered to the abdominal wall, just beneath the level where I had opened the peritoneum, and tacked down with carcinomatosis nodularity.  It was felt as though the distal bowel was not acceptable to bypass too plus with the chronic distention, a leathery bowel and being covered with tumor was not expected to heal well.  There is an area of potential stricture, but it split in half proximal to where things began to decompress into the right lower quadrant mass.  It was then cleared along the mesentery on either side of the large   mesenteric deposit that was tugging to obstruct the bowel.  The GIA 75 staplers were fired across the proximal and distal  aspects of this area, and then the section of mesentery was divided between Kelly clamps and tied up with silk ties.  The specimen was sent to Pathology for frozen section, and then permanent section.  The proximal bowel had a Glassman clamp placed.  The staple line was removed with cautery.  The pull
suction was placed into the bowel and suctioned immediately adjacent contents, this was with the Glassman clamp.  ______ was  controlled with multiple towels as well as laps.  The fluid was very thickened, and really had very little leakage at all during this entire small bowel decompression process.  The Glassman clamp was released and a small bowel was ultimately milked from the ligament of Treitz all the way down distally to the point of the transection.  There was removal of approximately 8 L of enteric contents with marked decompression of the small bowel. Once this was completed, and the bowel was decompressed, a Glassman clamp was applied across the enterotomy.  Attention was then turned distally where once again, the corner edge of the staple line was removed with a Glassman clamp placed.  The local enteric contents removed followed by opening of the Glassman clamp, and the more distal contents were aspirated free.  Once again, there was only scant spillage of enteric contents because the material was so thick.  Once the distal bowel was decompressed, a Glassman clamp was placed across this enterotomy site.  At this point, the abdomen was better explored, and the right lower quadrant was felt to be unresectable.  The pelvis was dense with carcinomatosis, as was the entire perineum, particularly in the lower abdomen.  The omentum was basically   caked with carcinomatosis deposits.  There was carcinomatosis on the liver, up along the diaphragm, along the edges of the stomach.  There were no palpable pancreatic mass.  The colon had no palpable distinct masses beyond the external carcinomatosis lesions.  The spleen also appeared to have no solid masses, but did have carcinomatosis involved as well.  The likely etiology of this tumor was on the hard mass in the right lower quadrant that was otherwise not discernible or identifiable.  At this point, the abdomen was irrigated, and the irrigant suctioned free.  A right side ostomy site was chosen.  A core of skin and soft tissue was taken.  A linear with some cruciate extensions laterally were made through the rectus muscle.  The posterior peritoneum was opened as well.  The proximal distal limbs of small bowel were brought through the opening to perform an end ileostomy with adjacent mucous fistula.  It externalized beyond  the limits of what was needed.  The midline fascia was then reapproximated with interrupted 0 Ethibond sutures in interrupted fashion.  Subcutaneous tissues were irrigated.  The skin edges were reapproximated with surgical staples.  Sterile towel was applied at this area.  The approximately 1/3rd of  staple lines were removed from the two ends of the bowel,     starting from the already made enterotomy site before.  The proximal end ileostomy and the more distal mucous fistula were completely matured with interrupted 3-0 Vicryl suture.  The mucous fistula caught cranially and the functioning ileostomy was below this.  An ostomy appliance was applied.  Sterile dressing was applied to the midline incision with antibiotic  ointment placed.  The patient tolerated the procedure well, was ransferred to recovery room in stable condition


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## rollinholy

as far as I can tell I think you can assuming I chose the correct code 47420, they are not components of one another but do you bill for the exploratory lap as well--we can't get paid for that when other procedures are done


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## Bready

47420 is incorrect. Use 44021-59-- if it is not bundled into your other code(s).  44121 is an add-on code for 44120.  Are you sure you want to use this? Look at the op note again-- your physician did an ileostomy with mucofistula. Take a look at the colectomy codes and see if they are more appropriate to what was actually done--CPT 44144.


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## hpierce

Bready said:


> 47420 is incorrect. Use 44021-59-- if it is not bundled into your other code(s).  44121 is an add-on code for 44120.  Are you sure you want to use this? Look at the op note again-- your physician did an ileostomy with mucofistula. Take a look at the colectomy codes and see if they are more appropriate to what was actually done--CPT 44144.



I had looked at code 44144, however I thought this was for the large intestine. In this procedure they resected the small bowel...is there a "small bowel" version of 44144? That is why I was leaning towards 44125. I can see using 44021 for the decompression.

Thanks for hashing this out with me!!
Heather, CPC


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## Bready

Hi Heather,
I apologize if overcoded this.  Look back at your original cpt code and see if you can add 44310 which would cover the ileostomy portion and if yes, then your golden.  It was fun


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## AWright421

44144 Colectomy, partial; with resection, with colostomy *or ileostomy *and creation of mucofistula

"The physician resects a segment of colon. The proximal and distal ends of colon are brought through the abdominal wall onto the skin as a colostomy and mucus fistula. The physician makes an abdominal incision. Next, the selected segment of colon is isolated and divided proximally and distally to the remaining colon and removed. The proximal end of colon or terminal ileum and the distal end of colon are brought through separate incisions on the abdominal wall onto the skin as an ileostomy or colostomy and mucus fistula. The initial abdominal incision is closed."

CCI Edit - Procedure [44144] on claim line 1 and component procedure [44021] on claim line 2 are unbundled. The Standard Policy Statement reads "More extensive procedure". The use of an appropriate modifier may be allowed.


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