# What's the code for pancreaticogastrostomy



## dmaguire (Jul 8, 2011)

I have a provider that performed a pancreaticogastrostomy and I am hitting a brick wall when it comes to finding a code to report for this procedure.  Can anyone out there help me out in finding a code to support this service.

Danielle


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## lindacoder (Jul 8, 2011)

can you post the operative note?


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## surgonc87 (Jul 8, 2011)

I think you have to post the op note for this one


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## dmaguire (Jul 8, 2011)

*Op Note*

We disected  the pandreas away fromt he portal and splenic veins.  We created an anterior gastrostomy.  We placed a posterior row of 3-0 silk from the stomach serosa to the pancreas.  We made a posterior gastrotomy and brought the pancreas up through the gastrostomy and then perfromed an anastomosis between the full thickness of the stomach and the pancrease using 3-0 poloysorb.  We then completed the anterior row of 3-0 silks from the stomach to pancreas.  With this we completed, we closed the interior gastrostomy using a running 3-0 polysorb suture followed by 3-0 silk Lembert sutures.  The nasograstric tube was positioned.  The Jackson-Pratt drain was placed through a seperate stab incision.  The cut edge of the pancreas on the patient's right side  of the partal vein was cogaulated using hte electrocautery.  We then closed the internal obique and transversus and the posterior rectus sheath with a #1 vicryl.  We closed the external obique and anterior  rectus sheath with #1 Prolene and then some interrupted Prolene sutures in figure-of-8 fashion were used to close the upper part of the incision.


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## surgonc87 (Jul 8, 2011)

We just need to know the medical reason for this surgery.


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## dmaguire (Jul 8, 2011)

recurrent liposarcoma of the retroperitoneal.


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## surgonc87 (Jul 8, 2011)

Sorry, still does not help put the big picture together now that there might be other resections. Please post whole op note?


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## dmaguire (Jul 11, 2011)

*OPERATION*: Resection of retroperitoneal liposarcoma en bloc with partial hepatectomy and partial pancreatectomy; resection of ileocolic anastomosis; redo  ileocolic anastomosis; extensive lysis of adhesions; pancreaticgastrostomy.

*INDICATIONS: * This patient is a 51-year-old femal with a history of recurrent liposarcoma.  She presents for resection of a new tumor which was in the porta hepatis.

*FINDINGS:*  Tumor involving the hepatic artery, protal vein, pancreatic neck, duodenum and bile duct.  An enterotomy was made in the previous ileocolic anastomosis, necessitating resection and reanastomosis.


*PROCEDURE: * The patient was brought to the operating room.  General endotracheal anesthesia was administered.  A foley catheter and approrpriate lines were placed.  The abdomen was prepped and draped in sterile fashion.  The initial incision was a hockey-stick-type incision beginning in the upper midline and extending right subcostally.  Ultimately this was extened down the midline.  Electrocautery was used to pen the incision along its entire length.  A time-consuming and tedious dissections ensued as we performed lysisi of adhesions for several hours prior to getting down to the meat of the matter.  The patient had a large tumor in the prta hepatis.  This was involving the liver.  We scored the liver capsule using electrocautery.  WE then deepened this using the Aquamantys, and staplers with vascular tan loads were fired across the liver to take it en bloc with the tumor.  A time-consuming and tedious dissection then ensued as we dissected out the hepatic artery.  We ligated the right gastric artery as well as the gastroduodenal artery while dissecting the tumor off the hepatic artery, portal vein and bile duct.  We surrounded these structures with vessel loops and continued working our way up the pancreas.  We tried to dissect the pancreas off the tumor but ultimately ended up dividing across the neck of the pancreas,  taking a portion fo the pancreas with the tumor.  Ultimately we were able to deliver this portion of tumor from the operative field. There were portions of hte tumor that were necrotic and simply fell apart.  When this was completed, on the way into the abdomen we created an enterotomy in the ilecolic anastomosis.  This anastomosis was taken down.  We had to mobilize the colon and then in time-consuming and tedious dissection lysed adhesions until we mobilized enought of the terminal ileum.  Ultimatley an ileocolic anastomosis was performed,  taking off a portion of the staple line and firing an EndoGia with a 63.5 load and closing the resultant opening with an EndoGia with a 63.5 load.  The mesenteric defect was closed with 3-0 silk.  With this completed, we dissected the pancreas away from the portal and splenic viens.  We created an anterior gastrostomy.   We placed a posterior row of 3-0 silk from the stomach serosa to the pancreas.  We made a posterior gastrostomy and brought the pancrease up through this gastrostomy and then performed an anastomosis between the full thickness of the stomach and the pancreas using 3-0 Plysorb.  We them completed the anterior row of 3-0 silks from the stomach to pancreas.  With this completed, we closed the interior gastrostomy using a running 3-0 Plysorb suture followed by 3-0 silk Lembert sutures.  The nasogastric was positioned.  The Jackson-Pratt drain was placed through a separate stab incision.  The cut edge of the pancreas on the patient's right side of the protal vein was coagulated using the Aquamantys.  We irrigated and suctioned and obtained hemostasis with electrocautery.  We then closed the internal oblique and transversus and the posterior rectus sheath with #1 Prolene and then some interrupted Prolene sutures in figure-of-8 fashion were used to close the upper part of the incision.  THis was followed by 2 running segments of #1 Prolene in the distal part of the incision.  The subcutaneous tissue was irrigated.  The skin was coapted with staples.  Dressings were applied.  The pateint tolerated the procedure well.  She was extubated and taken to the recovery room in stable condition.

*POSTOPERATIVE DIAGNOSIS:  * Recurrent Liposaracoma of the retroperitoneum


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## surgonc87 (Jul 11, 2011)

Better...this is how I would code this. Also have MD add specific total time for lysis of adhesion so you can modify the primary CPT with a 22.  Also Have MD add total size of tumor removed intraabdominal to report 49203 series. Also the ileocolic anastomosis is iatrogenic so it cannot be reported.

DX : primary, any secondary?,LOA, co morbidities. 

49205-m-22
48145 into an unlisted code mocking the fee
(48999 pancreatectomy, distal subtotal with pancreaticgastrostomy)

MS


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## dmaguire (Jul 11, 2011)

Thank you!  I was really hoping we did not have to use an unlisted code but....we do.  

Danielle


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