# Laparoscopic assisted ileocolonic resection...



## Jarts

I am unsure in coding the following procedure:

pt recently underwent screening c-scope and they tattood a tubovillous adenoma in the ileocecal valve and also in the transverse colon.


Using the open Hassan technique the infraumbilical port site was placed under direct vision.The abdomen was insufflated to 15 mmHg with CO2. The pt was placed in the head down position with the right side up. A 5 mm lateral port and infraumbilical ports were then placed under direct vision. The terminal ileum and cecum were then mobilized along the lateral peritoneal attachments using the Harmonic scalpel as well as both blunt and sharp technique. This allowed us to move up to the hepatic flexure. At the hepatic flexure, there were multiple adhesions from his prev open chole. These were taken down with both sharp and blunt dissection. This also allowed us to further mobilize the hepatic flexure. At this point, we began the search for the tattoo site by elevating the omentum. We then identified the lesion in the distal transverse colon. At this point, we then made the decision due to the large omental, thickened tissue that it would be very difficult to continue the laparoscopic technique given the pt's size  and amount of adipose tissue int he abdomen. Thus, we returned our attention to the right lower quadrant to make sure that the ileocolonic resection should be done without extending the incision inferiorly. Once satisfied with that, we then opened the abdomen in the superior aspect of the umbilicus and placed the bookwalter retractor in place. We then mobilized the splenic flexure by taking down the omental colic ligament and attachments down to the mesentery entering into the lesser sac and working down around the splenic flexure. The splenic flexure was completely mobilized down to the mid descending colon. The specimen was clearly identified and appeared to be fairly firm and hard, somewhat worrisome for a carcinoma. Once having the area completely mobilized, we then chose our sites for resection, which were at least 10 cm proximal and distal to the lesion. Both the proximal and distal bowel were divided using the GIA stapler. The mesentery was then divided between Pean clamps down to the root of the mesentery. Then, the specimen was removed from the abdomen. We then proceeded with a functional end-to-end, partial side-to-side stapled anastomosis. The posterior row of 3-0 silks were then placed on the medial aspect of each side of the colon. An enterotomy was made in the ends of the bowel. The GIA-75 stapler was then passed through each lumen and fired. This was done on antimesenteric border. The anastomosis was then reinforced with interrupted 3-0 silks. The enterotomy was then divided as was the nipple of bowel with the TA-90 stapler. The TA-90 was then reinforced with interrupted 3-0 silks. The mesentery was then closed with running 2-0 Vicryl. At the end of the procedure, the vascular integrity of each side of the bowel was inspected. There was no tension on the anastomosis and the blood supply appeared to be excellent. His bowel was then placed in the mid abdomen. We then turned our attention to the right colon where the terminal ileum was fully mobilized and divided with the GIA-85 stapler. Then, the mesentery between the terminal ileum and the mid ascending colon was then divided between Pean clamps. The ascending colon was then divided with the GIA stapler and a second side-to-side stapled anastomosis was done with the GIA-75 stapler and TA-90 stapler. The mesentery was closed with running 2-0 Vicryl. The anastomosis was reinforced with interrupted 3-0 silks and was inspected for integrity as well as blood supply and there was no significant abnormalities. At the completion of the anastomosis, it appeared that the omentum was pulling due to its shear bulk on the anastomosis. Out of concern for putting tension on the anastomosis, the omentum was freed up from the superior bowel wall and then divided at the mid transverse colon using clamp and tie technique. The abdomen was then irrigated withe copious amounts of normal saline. The anastomosis were both inspected for any signs of any leakage. There was none, blood supplies were excellent to both anastomosis and the decisions was made to close...

physician coded:
44204-22
44213
44140-51


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## ekpehunter1

I think 44204,44213


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## Jarts

Do you think those two codes capture both the terminal ileal and cecal resection and distal transverse colon resection both with primary anastomosis?


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## Jarts

I am still not sure how we can get paid for both the ileocolonic resection AND the transverse colon resection?


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## acbarnes

I work for colorectal surgeons and see this from time to time. I would bill 44205, 44204-59, 44213. You have two seperate lesions and two seperate resections with anastamosis. Therefore, modifier 59 applies for the CCI edit. 

If you had two different diagnosis that would be helpful, but if they both come back with the same path as benign, they will be the same (211.3). For malignant you would use 153.1 for the transverse and 153.4 for the Ileocecal valve.   

If insurnace denies, file an appeal. Don't let teh insurance get away without paying. We get paid on almost all of these even in appeal. If you need help with an appeal you can contact me at abarnes@atlantacolon.com.

I hope this helps!

Anna Barnes, CPC, CGSCS


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## Jarts

YES! Thank you so much for your advice, Anna. 

A couple of other questions, though. Is 44205 appropriate without the colostomy? I think this is what confused me before - I don't find the specific code I really need.


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## acbarnes

44205 is a lap ileocolic resection. It does not include a colostomy but an ileocolostomy which means an anastamosis between the ileum and large intestine. Look at the description for 44160 (open code) with diagram on page 202 of AMA CPT 2009 Professional Edition if you have it. 

I hope this helps, it is a little confusing.


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## Jarts

OK!! Makes sense now. Thank you so much for getting back to me.
Julie


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## Jarts

Anna -
44204 WAS denied. I e-mailed you.
Julie


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