# HELP coding pancreatic necrosectomy...



## Jarts (Jul 14, 2009)

This surgery is not in my expertise at all. Would someone have advice on how to code the following?
Dr turned in:
48105
15734-51
15330-51
15331


POST OP DX: 
1. Open abdominal would with need for abdominal wall closure.
2. Necrotic pancreas with intra-abdominal abscess in the left upper quadrant and intraloop abscesses in the small intestine.

PROCEDURES PERFORMED:
1. Exploratory laparotomy with partial pancreatic necrosectomy.
2. Drainage of intra-abdominal abscess.
3. Lateral abdominal wall components release.
4. Closure of abdominal wall with the use of AlloDerm.


FINDINGS: Upon entry into the abdomen, there was a moderate amount of adhesions to the anterior abdominal wall which were taken down. Upon entering into the abdomen and mobilized from the abdominal wall, we did identify a significant tail of the pancreas abscess cavity and nectrotic pancreas which was debrided. There was also a smaller left upper quadrant abscess cavity which was also drained.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after proper identification, confirmation, and PARQ. The patient was prepped and draped in normal sterile fashion. The previous placed mesh was removed by removing the sutures and removing it from the anterior abdominal wall which was relatively straightforward. We then identified the fascial layers and carefully dissected the adherent bowel and contents from the anterior abdominal wall and working lateral. Working laterally on the left side, we again encountered a pocket of pus which was at the tail of the pancreas which was further opened and we clearly identified necrotic pancreatic tissue. This was debrided using ring forceps clamps. The wound was then irrigated with copious amounts of normal saline was a small amount of bleeding which was controlled with electrocautery. Cephalad to the tail of the pancreas. There was also a splenic abscess which was also opened and drained. The abdomen was then irrigated with copious amounts of normal saline. There were numerous adhesions to the anterior abdominal wall, which were taken down just enough to allow us to mobilize the abdominal wall. Careful attention was made to prevent an enterotomy due to the poor healing given his chronic medical condition as well as the amount of adhesions in his abdominal cavity. Once having the bowel fully mobilized, it was inspected for any signs of any enterotomies. There were no significant enterotomies noted there was no evidence of any succuss in the abdominal wall area. There was no evidence of any succuss spilling into the abdomen where we had been operating and dissecting.

At this point, we decided to further mobilize the fascia. The subcutaneous tissue was elevated from the fascial layer all the way lateral to the rectus sheath. Beyond the lateral rectus border of the rectus sheath. The fascia was then incised lateral ot the rectus sheath to allow further mobilization of the anterior abdominal wall medially an attempt to allow adequate relaxation to allow closure. Once having both sides and inferior and superior aspects mobilized became clear that we would not be able to completely close the abdomen. Thus, the decision was made to bridge the gap with AlloDerm. A 6x12 cm piece was placed in the inferior portion of the wound an secured into position with interrupted 0 Ethibond sutures in 2 rows of reinforcement with the placement of a malleable below the AlloDerm to prevent any injury to the underlying bowel. The 12 cm piece that extended up to the mid portion of the incision. At that point, the fascial defect was a little bit wider and thus a 12x12 cm piece of AlloDerm was then placed in a diagonal position with a diamond shaped and this allowed adequate coverage of the mid to upper portion of the wound. This was again secured into the fascial layer approximately 2 to 3 cm lateral on each aspect with a double row of interruped 0 Ethibond sutures. The 2 edges of the AlloDerm were then sutured together with interrupted and running 2-0 Ethibond. The subcutaneous tissue was irriagated with copious amounts of normal saline and inspected for hemostasis, which was well controlled. A 15-French round Blake drain was then placed in the subcutaneous tissue overlying the lateral components release and sutured to the anterior skin. The subcutaneous tissues were then reapproximated, the skin was reapproximated and then closed with large vertical mattress sutures of 2-0 nylon to close the skin.

ADDENDUM:  Prior to closure of the abdomen and placement of the AlloDerm a large round Blake drain was placed in the tail of pancreas in the area and the necrosectomy and brought out with separate stab incision lateral to the rectus sheath and sutured into position with interrupted 3-0 nylon.

Thanks for any and all input,
Julie


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## mjewett (Jul 16, 2009)

I agree with the way your doc. coded it. 

That quite a surgery, the RVU's on code 48105 are HUGE!!!!


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## Jarts (Jul 16, 2009)

That's what surprised me so much!!! The RVUs are insane!
Thanks for your confirmation.


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