# Second request--need help with CPT code.



## coder25 (Jan 21, 2010)

PROCEDURE:  Reopening of recent laparotomy/abdominal washout/excision of portion of biliopancreatic limb/transection of jejunum at previous anastomosis/end-ileostomy/placement of Wittmann patch.

PROCEDURE:  After a timeout was called, we explored the peritoneal cavity and broke up the small amount of adhesions that had formed since the last surgery and reevaluated the RUQ for any signs of biliary dranage from previous anastomosis of the duodenal pouch onto the jejunum.  We followed the native limb that had been anastomosed to the stomach, the jejunum down to the area of the anastomosis with the previous biliopancreatic limb.  We then visualized the common channel that ended in a blind pouch in the terminal ileum from previous right hemicolectomy.  Following the previous biliopancreatic limb proximally, we did note the area that had been tented up previously with a large serosal tear continued to have a large serosal tear with questionable serosal health.  At this time, we measured the bowel length from the stomach to the common channel and to the stapled off ileum, and it was noted to be approximately 60 inches.  To minimize the risk of this patient developing short=gut syndrome, we decided to maintain as much of the previous biliopancreatic limb as possible, and then reanastomose it within the continuity of the bowel.  At this time, the area of the biliopancreatic limb that was of questionable viability was transected off of the remaining bowel.  We then, using Kelly clamps and silk ties, divided the mesentery to the area of transection and then the specimen was sent to pathology for the evaluation.   Evaluating the previous anastomosis from the duodenal switch, we made a small window in the mesentery at the bowel edge of the native limb.   The bowel was transected at the level of the anastomosis.  The proximal bowel was placed next to the proximal area of transection, from the previous biliopancreatic limb.  Two enterotomies were made and an anastomosis between the bowel connected to the stomach and the bowel connected to the terminal ileum.  Once the anastomosis was created, the remaining enterotomy was then closed with simple sutures of 2-0 silk.   The abdomen was washed out extensively and then turned our attention to creating the ileostomy.

A circular defect was made on the abdominal wall of the RLQ and using electrocautery this was continued down through the skin and subq tissues to the level of the fascia.  A cruciate incision was made into the fascia and continued down to the level of the peritoneum.   The defect was made within the peritoneum and this was stretched to the diameter of the terminal ileum.  During our dissection, the inferior epigastric arter was injured requiring clamping x2, transected, and tied with silk sutures.  Once the bleeding was controlled, we continued with our ostomy defect, enlarging it to the size of the e4dematous large terminal ileum.  The terminal ileum was brought out through the defect.  A serosal tear occurred repaired with silk sutures. At this time, the end of the bowel staple line was excised and ostomy was matured to the anterior abdominal wall with Vicryl sutures.  Once the ostomy was completed, closure of the abdomen was started.  Due to loss of domain, a Wittman patch was placed for temporary closure and tightening progressively.  

Any help is  very appreciated!.  I can get the reopening and abdominal washout as well as the enterotomies, I am just not sure of the others.


----------



## mjewett (Jan 21, 2010)

I was looking at code 43850, what do you think?  Sounds like this pt previously had a biliopancreatic diversion with duodenal switch (43845), and now this is being revised because the bowel ends of the anastomosis are not viable. So I think code 43850 would work.


----------



## coder25 (Jan 21, 2010)

Yes this patient did have the duodenal switch operation eight years ago. 

I saw that code 43850, but I wasn't sure due to the end ileostomy  and primary anastomosis.  

Just want to double check, I would still bill out 49002 for the reopening and the two enterectomies, I am correct?

Thanks for your help.  It is so much appreciated!

Peggy


----------

