# Please help with CPT coding of slipped lap band, internal hernia, laparoscopically



## mjfrog1 (Jun 9, 2014)

*Any help with the CPT coding, would be greatly appreciated!!*

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PREOPERATIVE DIAGNOSIS: Abdominal pain.

POSTOPERATIVE DIAGNOSIS: Internal hernia with Lap-Band slip.

PROCEDURE PERFORMED: Diagnostic laparoscopy. Reduction of internal hernia and removal of Lap-Band.


INDICATION: This is a 39-year-old female who has been having episodes of abdominal pain and reflux. The patient was worked up with EGD where she was found to have ulcers, however, she is being treated with Nexium. The patient had a CT scan which showed a possible soft tissue mass in the stomach. The patient continued to have abdominal pain and now is being brought for diagnostic laparoscopy.


GROSS FINDINGS: The patient was noted to have evidence of previous Lap-Band surgery. She was noted to have an internal hernia of her stomach through the Lap-Band. I was able to loosen the Lap-Band and remove this and then reduce the internal hernia without difficulty.



PROCEDURE IN DETAIL: After the patient was identified and consent was signed she was brought back to the operating room and placed in supine position. General anesthesia was administered. Endotracheal tube was placed per the Anesthesia Department. The area was prepped and draped in the usual sterile fashion. First an incision was made 9 fingerbreadths below the xiphoid process just left of midline with a #15 blade scalpel. Next a Veress needle was placed. Pneumoperitoneum was obtained. Next a 12 mm trocar was placed under direct visualization into the abdominal cavity. Using this I was able to identify that the patient had an internal hernia of her stomach. At this point I was able to place two right-sided 5 mm ports. A subxiphoid 5 mm port which was removed and then liver retractor was used to retract the left lobe of the liver. Next there was an 11 mm port placed between the initial incision and the patient's left lateral port. Using these ports I was able to triangulate the stomach and using the graspers I was able to manipulate the stomach were it had herniated. There was noted to be a Lap-Band in place and the inferior portion of the stomach had herniated through the Lap-Band. At this point the Lap-Band had scar tissue around it which was removed with electrocautery. Then I was able to manipulate the Lap-Band and open it, however, the hernia would not reduce. At this point I had to cut the Lap-Band in half with Endoshears and then remove the Lap-Band completely. After it was completely removed it was placed in an EndoCatch bag and removed from the abdominal cavity. The area was reinspected. I was able to note that the herniated stomach reduced. At this point the area was inspected and irrigated. There was no evidence of any bleeding or leakage of gastric contents. At this point pneumoperitoneum was released. The trocars removed. Incisions were closed with interrupted buried 3-0 Monocryl suture. 

The initial incision was extended. We were able to identify the old Lap-Band port. I was able to grasp this with trocars and electrocautery was used to divide the tissue from the port and remove the port in its entirety. I then closed the rectus defect with a figure-of-eight 0-Vicryl and UR-6. The wound was irrigated. Next simple interrupted 3-0 Monocryl was used to close the dermis and skin incisions. Steri-Strips were placed. 05% Marcaine with epinephrine 20 mL were used to anesthetize the skin incisions. The patient was then awakened, extubated and transferred to PAC Unit in satisfactory condition.

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Thanks for any help.

Sue, CPC, CCS-P


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## lindacoder (Jun 10, 2014)

If I'm reading this correctly it looks like when he removed the band that the hernia reduced itself so I would just code removal of the band and port - CPT 43774. If he wants to bill for reduction of the hernia the code would be unlisted 44238 with comparison to the open code 44050.


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## mjfrog1 (Jun 10, 2014)

Thank you for the quick response, I really do appreciate it!! I will look into that code.

Sue


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