# Help with coding this



## amy_mousie (Jan 6, 2012)

PROCEDURES:
1.  Exploratory laparoscopy with splenic flexure mobilization
2.  Sigmoid resection with primary anastomosis.
3.  Lysis of adhesions.
4.  Primary ureteral repair of over 60 frensh double J 20 cm ureteral stent

DESCRIPTION OF PROCEDURE:
iNITIALLY, WE MADE A SUPRAUMBILICAL INCISION WITH 11 BLADE SCALPEL AND USED VERESS NEEDLE TO OBTAIN PNEUMOPERITONEUM TO 15 MMhG.  lAPAROSCOPE WAS INTRODUCED TO EVALUATE FOR VISCERAL VASCULAR INJURY.  NONE WAS SEEN.  LAPAROSCOPY WAS PREFORMED.  

Patient noted to have significant adhesions to her anterior abdominal wall just above where we had placed our trocar with also obvious mesh with tacking.  We identified her sigmoid colon which was significantly adhesed to the side wall as well  as to her adnexal structures including her uterus.  Tried to dissect the plane to free the colon from the both sidewalls and her uterus.  Very difficult dissection and photodocumentation was preformed of this.  We were able to completely mobilize the colon away from the sidewall of the adnexal structures.  I went ahead and mobilized the colon up along the white line of the Toldt all the way to the splenic flexure.  Once this was completed, we careflly identified in the retroperitoneum, and ureter.  Did normal peristalsis.  We preformed open colon resection at this point.  

Patient's pneumoperitoneum was released.  We made a lower midline vertical incision approximately 8 cm in length.  Dissected down through fat/subcutaneous tissue.  Opened fascia lengthwise then opened the peritoneum at the length of the incision.  We progressively tried to bring the adhesed and diseased colon up into the wound.  There was stilll significant amount of inflammation to the lateral sidewall inferiorly.  We dissected this down.  In the process the cautery did partially transected the ureter.  We went ahead and finished our mobilization of her colon and used Echelon 60-mm stapler to transect the colon both proximally and distally using the Ace Harmonic to take down adjoining mesentery.  We performed our bowel anastomosis sisde to side functional end to end anastomosis was done.  Did a handsewn the common enterotomy closed as there was modest amount of tension on the anastomosis.  Once this was complete hemostasis I attended the ureter.  Placed a finger under the ureter which had been fairly well skeletonized during the dissection.  It was very clear partial injury to it.  We inject indigo carmine intravascularly and this was confirmed with blue dye indicating that the right side of the ureter was functional as well as we had indigo carmine through our structure confirming that this was the ureter.  With assistance from Dr._________________we repaired this.

Once the ureter repair was complete we irrigated thoroughly and assessed for hemostatsis.  Closure of wond was done and dressings were placed.  

HOSPITAL CODES:  45.76, 45.94, 56.82, 54.59, 59.8
CPT CODES:   I am crossing between 44130 or 45550 Sigmoid resection with primary amastomosis.  
45820-45825 Primary ureteral repair 
44139  Laparoscopy with splenic flexure mobilization

ANY ASSISTANCE WITH CPT CODING WOULD BE APPRECIATED.  THANK YOU SO MUCH

Amy Wright
CPC-H, CCP-H, CPC, CCP, CMBS


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## robin5354 (Jan 6, 2012)

Hi Amy,
I would not bill for the repair of the ureter since the surgeon made the injury to that ureter...so that is not billable for him to repair an injury he made. 

As for the resection of the sigmoid, I would bill that as 44140, partial colectomy. 45550 includes the pexy of the sigmoid, which I am not reading that he pexied it in the end.
Also, if you can get him to add the extra amount of time (more than normal)  it took him to take down the adhesions, you would be able to add the 22 modifier. He states it was a very difficult dissection through the adhesions. 

44139 is not for a laparoscopic mobilization of the splenic flexure. That would be 44213 and I don't think you can add the lap code to the open code. 

You may end up just billing 44140. See if you can add the 22 modifier if he addends the note. Hope I helped you!


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## amy_mousie (Jan 10, 2012)

*Thank you so much*

I thought I could not do the repair since it happened during the procedure.

Appreciate your assistance.  This one just got to me.


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## sabrinaecob@gmail.com (Oct 10, 2012)

*HELP!!!Laparoscopic mobilization of splenic flexure of the colon*

PROCEDURE PERFORMED:
1.  Laparoscopic mobilization of splenic flexure of the colon.
2.  Laparoscopic resection of the 12th rib.
3.  Laparoscopic ventral hernia repair with mesh.

INDICATIONS:  The patient is a 64-year-old female who underwent a partial 
nephrectomy at ** in the past.  Since that time, she has had 
chronic pain in the left flank region.  A CT scan showed a bulge in a hernia 
at the prior partial resection of her left 12th rib.  She has had pain there 
and a large hernia and with that in mind, she was consented for surgery.

DESCRIPTION:  After informed consent was obtained, preoperative antibiotics as
 well as subcutaneous heparin were administered within the hour of the 
procedure in the holding area.  She was then transported to main operating 
room #11 at Sacred Heart Hospital on ***  A surgical timeout was 
performed per CMS guidelines and general endotracheal anesthesia was applied. 
 Sequential compression devices were in place and functioning at time of 
induction.  A Foley catheter was placed and then the patient was placed in a 
right lateral decubitus position at 45 degrees.  Her abdomen was prepped and 
draped in normal sterile fashion.  Initially, a Veress needle was placed 7 cm
 from the xiphoid towards the left rib in the left upper quadrant.  A 5-mm 
trocar was then inserted after creating a 2-L pneumoperitoneum keeping 
pressures less than 12 cm of water.  This was created with a Veress needle.  A
 5-mm trocar was then inserted in the left mid abdominal region under direct 
visualization.  After inspecting that, there was no obvious injury to any of 
the intra-abdominal structures.  A 12-mm port was placed just to the left of 
the midline.  An additional 5-mm port was placed in the left lower quadrant. 
 Initially, the omentum was reflected towards the stomach.  The colon was 
grasped and the entire white line of Toldt was taken down in the prior surgery
 bed of her partial nephrectomy.  This was carried up onto the splenocolic 
ligament and the splenocolic and superior aspect of the lienocolic ligaments 
were mobilized.  There was a lot of omentum and fat attached to the ribs in 
the splenic bed.  This was mobilized with hook Bovie cautery until I was able
 to get in the retroperitoneum and get deep to Gerota's fascia and mobilized 
Gerota's fascia off of the posterior ribs.  The entire remaining left kidney,
 colon, and the retroperitoneum were reflected off of the ribs in the right 
posterior lateral sidewall.  Hemostasis was ensured.  Occasionally, I did get
 into some small pinpoint bleeders associated with the rib beds and these were
 controlled easily with hook Bovie cautery and some mild suction.  After 
mobilizing the inferior pole of the spleen off of the ribs, I then identified
 the ventral hernia as well as the rib in question.  The rib was scored and 
mobilized 2.5 cm and then a standard open rongeur was passed through the 12 mm
 port and I resected at least 2 cm of this rib and clean this rib edge off so
 that it would retract within the muscle layer.  I then closed the muscles 
over the exposed portion of the end of the rib after ensuring hemostasis with
 0 Vicryl sutures in an interrupted fashion.  These sutures were then carried
 up onto the ventral hernia defect and the ventral hernia was closed primarily
 again with 0 Vicryl sutures.  These were merely incisions created exterior to
 the body on the abdominal wall and a 0 Vicryl suture passer was used to 
reapproximate all the muscles.  Having satisfactory primary closure over this
 area, I then placed a piece of Parietex mesh that was 15 x 20 cm in size and
 orientated it in the correct manner.  I secured it posterior to the spleen 
along the chest wall and reflected this anterolaterally towards the midline of
 the patient completely covering the entire ventral hernia defect position.


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