# Very unsure as to how to code this one. Please help!



## coder25 (Feb 1, 2010)

Good morning all, 

The patient previously underwent a Whipple procedure and subsequently developed massive intra-abdominal hemorrhage.

Pressure was held on the incision and the previous RUQ incision was subsequently opened the remainder of the way.  In order to gain access to free a portion of the abdomen, the incision was extended laterally and medially.  The abdomen was able to be accessed and subsequently adhesions to the anterior abdominal wall were bluntly taken down as the abdomen was opened; tamponade was released.  A massive amount of blood was released from the abdomen.  The abdomen was immediately packed with multiple lap pads in the RUQ laterally.   

Sutures from the previously pancreatic drain were taken down and the drain was removed.  This allowed the bowel to be released from the side wall of the abdomen.  The defect was then reapproximated using 2-0 silk sutures.  The biliopancreatic limb was then reflected medially in attempts to gain access to the bleeding source.  There again was massive ongoing hemorrhage.  The region lateral to the hepaticojejunostomy was packed as this did not appear to be the immediate source of the hemorrhage.  At this time, we felt it necessary to obtain access to the gastroduodenal artery, feeling this is the most likely source of the bleeding.  The overlying colon and omentum were bluntly dissected away from the gastrojejunostomy and the biliopancreatic limb.  In order to gain additional exposure, an extension of the incision up the superior midline was made. The bleeding source was identified in the region of the hepatic artery and this was ultimately able to be controlled with finger pressure and packing.   Pressure was held while anesthesia was allowed to catch up with the blood loss.   With further dissection and suction, the bleeding source was clearly identified.  We placed three 3-0 Prolone interrupted figure=of=eight sutures over top of what appeared to a gastroduodenal stump.  On the 3-0 Prolones were placed, bleeding stopped.  The region was packed and the remainder of the RUQ of the abdomen was explored.  The biliopancreatic limb was evaluated and noted to be a hole in the region as well.  It was clear that the bowel had separated from the pancreatic anastomosis.  The enterotomy in the bowel was then oversewn using 2-0 silk sutures.  The transected end of the pancreas was able to be identified; however, a clear duct was not able to be identified.  

The region was covered with Surgiflo and a pack was left over top of the hepatic artery.  The previously placed JP drains were replaced with a fresh drain.  In light of the patient's coagulopathy, massive hemorrhage, and overall clinical situation, we felt it was more prudent to continue with closure of the abdomen and return the patient to the ICU for ongoing resuscitation and warming. A trauma VAC pac was placed over top of the open wound.  

I would use the reopening of lap 49002, correct? I am not sure what to use for the control of the bleeding.   For the closure, would I use complex repair, trunk with a 76, 58 modifier?

Also, is there a code for the trauma vac pack or is that included?

Thanks for your help.


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## mjewett (Feb 5, 2010)

*post op whipple, hemorrhage*

I would only bill code 49002, reopening of laparotomy includes control of hemorrhage.  The wound vac placement is billed with 97605, but my experience is you can't bill the initial placement of the wound vac when it's done at the same time as a major surgery. You will be able to bill for the wound vac replacements during the post op period. If your doctor, is doing them, and if the patient is not enrolled in a home health agency. Also the repair of the enterotomies are usually not billable.

Now for the modifier: use modifier 78

58 Staged- is for when the procedure is planned ahead of time

76 Repeat- is for when the exact same procedure code as the initial surgery will be billed.


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