# anastomotic leak



## Jarts

I was hoping someone would have input on coding this surgery. I don't believe there is a code for oversew of anastomotic leak and I believe that would be the main CPT in this case which included:
1. Exploratory laparotomy with extensive lysis of adhesions of approx *3 hours.* _(separate procedure)_
2. Repair and oversew of an anastomotic leak.
3. Small bowel resection and repair of enterotomy x2. _(which according to another thread in this forum, should not be coded out at all)_ - *but I'm not sure if that is true in this case because it seems to be less of physician error and more of patient's body being so fragile.
*
Please advise

INDICATIONS: The patient is approximately 2 weeks out from a subtotal colectomy with ileorectal anastomosis for a synchronous colon cancer. He was admitted the night before with an abdominal wound infection and subsequently began having stool from his incision.

PROCEDURE FINDINGS: Small anastomotic leak in the anterior portion of the ileorectal anastomosis. He also had significant intraabdominal adhesions and basically a frozen abdomen with extensive firbrosis.

DESCRIPTION OF PROCEDURE: A previous midline incision was opened and carried into the abdominal cavity. Upon entering the abdominal cavity, we encountered a moderate amount of free enteric contents mostly located in the left lower quadrant. This was suctioned clear and then irrigated with copious amounts of normal saline. At this point, extensive lysis of adhesions was done which was very difficult and took approximately 3 hours to clearly identify where the anastomotic leak was. During that time period, we had 2 enterotomies and multiple serosal tears and it was almost impossible to clearly identify the proximal an distal bowel. After ultimately mobilizing the proximal bowel where the enterotomy was made in the left upper quadrant, this required a side-to-side stapled anastomosis to repair the enterotomy with a small bowel resection of approximately 3 inches. This was done with a GIA-75 stapler and a TA 55 stapler. there was also another mid-jejunal enterotomy that was made with a significant deserosalization, which required a functional end-to-end side-to-side anastomosis. At this point, further dissection proved to be virtually impossible due to any type of dissection resulting in extensive serosal tears.

At this point, a rigid sigmoidoscope was placed into the rectum after frog-legging the patient, and air was instilled into the rectum and the small anastomotic leak was identified in the anterior portion of the ileorectal anastomosis, and there was a staple that had disrupted from the anastomosis. This was reinforced in 2 layers with interrupted 3-0 Vicryl and interrupted 3-0 silk. The rectum was then instilled with air again, and there was no evidence of any further air leakage. A further attempt was made to identify both the proximal and distal bowel in hopes of obtaining adequate length to perform a diverting ileostomy but it became virtually impossible to determine proximal distal bowel and where we would be able to perform an ileostomy. Thus, the decision was made to place a drain at the anastomosis site and accept the repair that had been done so as to not cause any further damage to the bowel and any possible further enterotomies. The abdomen was then irrigated with copious amounts of normal saline, inspected for hemostasis, which was well controlled with electocautery. The bowel was inspected as best we could for any signs of any further serosal damage. Small serosal tears were repaired with interrupted 3=0 silks. A 15 French round Blake drain was then placed through a separate stab incision in the right lower quadrant and draped down into the pelvis at the site of the anastomosis. The fascial layers were then mobilized to allow closure and  a running looped #1 PDS interrupted #1 Vicryls were then used to close the bdominal wall. Subcutaneous tissue was irrigated with normal saline and the skin was closed with surgical staples with NuGauze placed in between the staples.

Julie


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## Jarts

Would anyone agree or disagree with coding this as:
44799 with a fee based on RVUs for 44005 (the lysis of adhesions) plus 20% for the extent of the adhesions (3 hours) and the extra work performed for the oversew of anastomotic leak.

I still can't decide if the small bowel resection and repair of enterotomyx2 would be billable...
If someone could help me take a stab at this I would be so 

Julie


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## ASC CODER

In my opinion your right you can't bill 44020 with 44005 but maybe you might want to consider 44020 with modifier 22?
you would have to send documentation but you would have that for the unlisted anyway. let me know how this turns out. Good Luck!


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## Jarts

44005 has a higher RVU than 44020 - so that is where I'm confused about which code to use - especially since the enterotomies were a by-product of the enterolysis.


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## ASC CODER

44005 is a seperate procedure.

“Separate Procedure” – What does It Mean?
The term “Separate Procedure” is part of the nomenclature found in the AMA Current Procedural Terminology® (CPT), in the “Surgery Guidelines” found in the front section of the book (page 45 in the 2007 Professional Edition). The guidelines state that some of the procedures and services listed in the CPT codebook that are commonly carried out as integral components of a total service or procedure have been identified by the term “separate procedure.”
The CPT surgery guidelines further state that the codes listed as “separate procedure“ should not be reported in addition to the code for the total procedure or service. In other words, report a separate procedure if it is not performed with a primary procedure that encompasses the “separate” one, or when it adds “appreciably to the time and/or complexity of the procedure.”
Medicare addresses the concept of integral parts and total procedures/services through use of the National Correct Coding Initiative. NCCI lists CPT codes that either: 1) represent components of other procedures and therefore, cannot be reported with that other procedure, or 2) represent procedures that cannot be performed on the same date of service, by the same physician, for the same patient – and therefore are not payable when billed on the same date.
Both Medicare and CPT acknowledge that there are times when a “separate procedure” CPT or an NCCI-bundled code may be performed independently, or may be considered to be unrelated or distinct from other procedures/services provided on the same date. In those instances, the physician can append modifier -59 to the “separate procedure” code. Modifier -59 indicates that the procedure is not a component of another procedure, but is a distinct, independent procedure.
A word of caution: Medicare does not always incorporate the CPT “separate procedure“ codes into the NCCI edits, but rather assumes that the coder will recognize coding scenarios in which a procedure or procedures are an integral part of the progression to the end procedure and, therefore, may not be billed separately. Conversely, Medicare may incorporate a CPT “separate procedure” code into the NCCI and list it as a code that can never be unbundled — regardless of the scenario.
Whenever you are coding for procedures and services, it is important to consider the Medicare NCCI edits, the CPT-designated “separate procedure” codes, and those procedures


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## Manas maity

In my option I would bill both the CPT codes 44020 and 44005. Although 44005 is separate procedure but we can append the 22 modifier since, the enterolysis performed was extensive and added significantly to the overall procedure. So the Op report should be submitted with the claim to describe the unusual work performed.
When submitting a claim that includes modifier 22, you should include an estimate of what you expect to be paid for the extra work involved in the procedure. Otherwise, you are leaving the decision up to the carriers, and they will potentially base your reimbursement on their standard allowable.
Finally, add 78 modifier since as per the Op report the patient had a subtotal colectomy with ileorectal anastomosis approximately 2 weeks ago.


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## Jarts

Thanks for all the input!


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