# 44025 and 44320?



## hsmith67 (Oct 25, 2011)

General surgeon did an exploratory laparotomy, on table decompression of the large bowel loop sigmoid colostomy. Any help to advise best way to bill this is greatly appreciated!

Here's the op note once patient was open: The large bowel was noted to be markedly distended to the point where there were serosal tears identified in the transverse colon and the left colon. There was significant ascitic fluid, approx 500-800 mL of ascites fluid was evacuated by suction. In the midtransverse colon a pursestring was placed on the tenia and the hole was made into the bowel. Suction was placed in the bowel to decompress the bowel. More than 1500 mL of liquid stool was evacuated from the bowel. There were large chunks of stool (nuggets) that were palpated in the cecum and the transverse colon which was milked towards this opening. The opening in the bowel was enlarged to allow passage of the stool. It was milked both distally and proximally from the sigmoid colon into the left colon, the splenic flexure and out through the opening in the transverse colon. Once the bowel was completely decompressed, the edges of the hole were placed together with Allis clamps and a TIA stapling device was used to close the defect in the bowel. The suture line was reinforced wtih 3-0 silk sutures. 

Attention was then turned to the pelvis where the uterus was palpated. It was densely adherent to the distal sigmoid colon. There was a metallic device palpated in the uterus. The area is with significant inflammatory reaction between the uterus and the colon. This might be the result of diverticular disease vs. foreign body reaction between the bowel and the uterus. The reaction is significant that it caused narrowing of the bowel lumen causing proximal large bowel dilitation secondary to partial large bowel obstruction. I am not sure whether the IUD had eroded through the uterine wall and partially into the wall of the bowel. This area represented the thickened section of the distal colon that appeared masslike on CT Scan. Decision was made to perform prodimal loop decompression of the sigmoid colon to the skin. An ellipse of skin about the size of a 25 cent piece was removed from the left side of the abdomen. The subcutaneous fat was removed down to the fascia where a cruciate incision was made. The side wall of the proximal sigmoid colon was brought up through the opening and onto the skin and was held in place with a bowel clamp. The abdominal cavity was irrigated, now with copious amount of bacitracin saline solution and evacuated by suction. Two JP drains were paced by stab incision in the left and right lower quadrant. The right lower quadrant JP drain was placed over the dome of the liver on the right side and the left lower quadrand JP drain was placed in the deep pelvis. The JP drains were secured onto the skin with silk sutures. The abdominal cavity was then closed with looped PDS and the skin edges reapproximated and closed with skin clips. The incision cleaned, dried, and an island dressing was applied. The ostomy was then macerated with 2-0 Monocryl sutures circumferentially. Once it was fully mature and ostomy appliance was fashioned around the ostomy site, a finger was introduced into the ostomy. It was patent and liquid stool just ran out from the opening. A ostomy bag....

So .. I'm coming up with a 44025 and 44320 -59. Anyone agree or disagree?

Thanks for any help!

Hunter Smith, CPC


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