# CPT Help Pls Rigid proctoscopy, Exp Lap



## bill2doc (Jul 31, 2012)

Looking at 49000 w/ 45300 ???? Can anyone help clear up the CPT codes for me. Don't think I am capturing all. Thank you!!

PROCEDURES:
1.  Rigid proctoscopy.
2.  Exploratory laparotomy.
3.  Extensive lysis of adhesions.
4.  Colostomy takedown.

DESCRIPTION OF PROCEDURE:  The abdomen was prepped and draped in standard fashion.  The procedure began using a rigid proctoscope to evaluate the rectal stump.  The rectal stump was irrigated with normal saline to clean out the anticipated stool.  The scope was then advanced and the stump appeared to be with healthy pink mucosa throughout.  There are no lesions identified.  The scope was advanced to 20 cm and the stump was not identified.  The attention was then turned towards the abdomen.  The stoma opening was closed using 3-0 silk.  The midline incisional scar was then incised.  This incision was carried through subcutaneous tissues to the fascia, where the abdomen was opened and entered.  The entry point picked was the most superior aspect, where the scar seemed the thinnest.  There was no bowel immediately beneath, but it was distally adherent.  This was dissected off of the midline incision and in a very systematic fashion and using this technique, the entire midline incision was then opened.  The bowel had  a significant amount of adhesions both to the bilateral abdominal walls and to itself.  Adhesiolysis occupied approximately 45 minutes of the procedure time.  Of note, there was a short segment of omentum that was adherent to the superior aspect of the abdominal wall, and there appeared to be a small granuloma in this area that leaked some purulent drainage.  This was cleaned and cultured.  The segment of omentum was then incised and passed off field as specimen.  Once the adhesiolysis was completed, the ligament of Treitz was identified and the bowel was then run.  There is no evidence of serosal tears that required repair.  The ileocolonic anastomosis initially performed in the first procedure was identified.  The colon was then traced into the hepatic flexure and then back to the stoma at the wall.  The rectal stump was easily identified and appeared to have a long segment that incorporated a significant portion of the sigmoid colon.  The colostomy was separated from the surrounding adhesed tissue along the anterior abdominal wall.  The skin around it was then circumferentially incised, and this incision was carried through the fascia and into the abdomen.  The stoma end was then brought through the fascial defect.  It was then brought over to the left side, where it appeared that the remaining transverse colon would easily connect to the remaining rectal stump.  The stoma was then divided with a linear stapler and passed off the field as specimen.  The ends of colon on either side were cleared of fat circumferentially.  The bowel was then anastomosed in an end-to-end stable fashion using a size 28 EEA stapler that was introduced through a colotomy in the transverse colon.  The anastomosis was then oversewn using Lembert sutures.  The longitudinal colotomy was then closed in a transverse fashion using a 2 layered handsewn technique with 3-0 Vicryl in the first layer and then interrupted silk Lembert sutures in the second.  The mesenteric defect was then closed using a running 3-0 Vicryl.  The abdomen was then copiously irrigated with sterile warm normal saline, and hemostasis was assured.  The fascial defect from the colostomy was closed in 2 layers using #1 Vicryl.  The skin edges of the colostomy were contracted using subcuticular of 3-0 nylon, leaving an opening that was large enough to pack a 1 inch Nu Gauze through.  The bowel was again run and noted to be without injury.  The fascia was then closed using a looped PDS.  The skin incision was then closed using staples.  The colostomy site was packed using the Nu Gauze.


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## cwpierce (Jul 31, 2012)

The codes involved in this report would be:

 44005 - Lysis of adhesions.
 44626 - Colostomy takedown.
 45300 - Rigid proctoscopy
 49000 - Exploratory laparotomy

49000 is a diagnostic procedure and will be global to the 44626 surgical package so we won't be using that code.

44005 will not be used because the lysis of adhesions is part of the bigger 44626 procedure.

That leaves us with 44626 & 45300. Now, 45300 is a diagnostic procedure and as we know diagnostic procedures are global to surgical procedures of the same anatomical site. We are allowed to code the proctoscopy in this case because it is occuring in a different body site. Yes, the intestines are in the abdomen but as for this report it would be considered a different anatomical site.

I would code this report as follows:

 1. 44626 - 22
 2. 45300 - 51

22: For taking 45+ minutes for Lysis of adhesions
51: For multiple procedures 

Please note that the above modifiers may or maynot apply depending on what rule the third party payor has in effect.

Hope this was helpful.


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## bill2doc (Aug 1, 2012)

I cannot thank you enough! I knew I wasn't getting it all.  Thank you for the wonderful breakdown! Have a great day


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