# Excision of abdominal wall mass with complex closure with mesh



## hedmiston (Jul 14, 2015)

I need help coding the complex closure of the following op report. 
The surgeon wants to bill 22905, 76998, 49560, 49568 & 47100. I don't agree with 49560 & 49568. I would bill 13101 & 13102 but, I read in the Medicare policy manual: Wound repair codes 12001-13153 should not be reported separately to describe closure of the surgical incisions.
Am I on the right track? Any help would be greatly appreciated. 

Pre/postoperative dx: Abdominal wall scar adenocarcinoma

Procedure Performed: Wide local excision of an epigastric abdominal wall mass using intraoperative ultrasound, liver wedge biopsies, and complex closure of the remaining ventral abdominal wall defect (incisional hernia) with a 15 x 15 cm Parietex mesh.

Findings: Intraoperative ultrasound was used to mark out an approximately 4 x 4 x 5 cm epigastric abdominal wall mass that was hypoechoic and irregular with posterior acoustic shadowing. The lesion was located at the site of a prior laparoscopic cholecystectomy epigastric port site and was notably firm and fixed extending to the peritoneum and invading the falciform ligament. Resection of the skin, subcutaneous tissue, fascia, and rectus abdominus musculature was required. Two white plaques on hepatic segment 4B were excised using wedge biopsies.

Description:An ultrasound was first performed. The abdomen was palpated, and there was noted to be the firm approximately 4 cm mass in the epigastric anterior abdominal wall. Intraoperative US was performed , and there was noted to be a heterogeneous  hypoechoic irregular mass in the anterior abdominal wass with posterior acoustic shadowing extending through the abdominal wall. The US was used to mark wide margins around the mass to guide the incision and skin flaps during surgery. 

An 8 mm elliptical skin incision was made in the midline vertically using the 10 blade scalpel with inclusion of the previous transverse port site scar. The incision was further deepened through the dermis and superficial subcutaneous tissue using electrocautery. Next, circumferential skin flaps were elevated. The skin flaps were elevated circumferentially to allow for adequate wide margins around the mass. The mass was periodically palpated to reoprient the skin flaps as well as to ensure that the adequate margins were obtained. In addition, care was taken to ensure that the skin flaps were thin enough to allow for an approximately 2 cm anterior as well. Once the skin flaps were elevated circumferentially enough to allow for a 2-3 cm margin circumferentially, electrocautery was used to dissect through the underlying subcutaneous tissue to the level of the fascia circumferentially. Next, electrocautery was used to dissect through the muscle and posterior rectus sheath, allowing for entrance into the abdominal cavity at a point along the inferior incision. Ligasure device was used to circumferentially dissect through the fascia, muscle, and posterior rectus sheath, again along the incision line that would allow for adequate 2-3 cm margins circumferentially from the mass.The undersurface of the peritoneum was palpated, and the mass was appreciated, but there was no extension past the level of the peritoneum. The mass did invade the Falciform Ligament, which was transected. There was no involvement of viscera. Once the mass had been circumferentially excised with inclusion of the anterior and posterior rectus sheath and muscle, the specimen was removed, and a short stitch was placed superiorly, a long stitch was left lateral, and a loop stitch along the falciform.

Abdominal cavity was examined with specific attention to the liver. There were 2 small lesions noted on the Segment IVB superior surface. Wedge biopsies were performed using electrocautery. Electrocautery was used to obtain hemostasis at the biopsy sites. There was noted to be a 2-3 mm epigastric nodule, and this was excised and sen for pathology as well. Abdominal cavity was irrigated and attention turned towards closure of the remaining abdominal wall defect.

A ruler was used to measure the remaining abdominal wall defect at approximatley 13-15 cm x 13-15 cm. Consequently, a 15 x 15 cm Parietex mesh was chosen to close the defect. First, six circumferential 2-0 prolene sutures were placed a the 12, 2, 3, 5, 6, 8, 9 and 10 o'clock positions. These sutures were all tied down and secured to the mesh. The mesh marked to orient the anterior and posterior sides with care taken to ensure that the posterior side would be shiny visceral side. The mesh was then placed in an underlay position underneath the fascia, and the corresponding spots for the sutures were marked circumferentially on the skin. The sutures were secured transfascially. After all sutures were pulled up through the skin circumferentially, they were tied down, securing the mesh in place for the underlay aspect. 2-0 Prolene sutures were used to secure the mesh to the anterior sheath for an additional inlay securement of the mesh. 3 Prolene sutures were used to secure the mesh in a running fashion. The mesh was examined and in good placement with good coverage and overlap of the abdominal wall defect. 

Wound was then irrigated, and Scarpa fascia was cloed with 3-0 Vicryl interrupted Vicryl sutures. The skin was closed with a 4-0 Vicryl running subcuticular stitch. The midline incision and the stab site incision of the suture were all dressed with Dermabond, and the drapes were removed.


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## cynthiabrown (Jul 16, 2015)

22905  47100  unlisted m/s code for mesh....cant bill closure


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## syllingk (Jul 17, 2015)

why can't you bill the closure? I disagree.  You are not biling the hernia repair which would exclude the closure but under the m/s code it says excludes complex repair, which means it is separately reportable.


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## cynthiabrown (Jul 20, 2015)

47100 would include a closure


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## hedmiston (Jul 20, 2015)

*Coding w/out liver bx?*

Thanks so much! How would you code this scenerio without a liver biopsy? 
Medicare vs. non Medicare patient?
*(Medicare policy manual: Wound repair codes 12001-13153 should not be reported separately to describe closure of the surgical incisions.)


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## syllingk (Jul 20, 2015)

love learning something new. Thanks Cynthia


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## vivekveevin (Aug 5, 2015)

i have doubt on above procedure hernia repair with mesh placement.47100 and 22905 are not include the mesh placement. can we code the hernia repair with mesh placement code

V.Vivek CPC


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## vivekveevin (Oct 12, 2020)

The patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below the skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. Which are the correct  CPT® codes assignment?


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## vivekveevin (Oct 12, 2020)

The physician performed a medial meniscectomy and removal of loose bodies from the lateral compartment. Select the appropriate codes for a Medicare patient.


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## vivekveevin (Oct 12, 2020)

17-year-old male presents to the emergency department after being involved in a car accident. The patient’s primary physician calls the orthopedic surgeon to the emergency department. The orthopedist diagnoses a sprained knee ligament. He places a long leg walking cast and instructs the patient to return to his office for follow-up care. What are the procedure and diagnosis codes?


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## vivekveevin (Oct 12, 2020)

The patient complains of chronic/acute arm and shoulder pain following bilateral carpal tunnel surgery. The patient is followed by pain management for over a year. The physician finally diagnoses patient with reflex dystrophy syndrome (RSD). The physician performs six trigger point injections into four muscle groups. Code the procedure(s).


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## vivekveevin (Oct 12, 2020)

A Grade I, high-velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then prepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure?


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## vivekveevin (Oct 12, 2020)

This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the teres minor muscle. Upon further dissection, a large mass was noted just distal of the IGHL(inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. The skin was closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?


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## vivekveevin (Oct 12, 2020)

Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulder Procedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient was placed supine on the operating table prepped and draped in usual sterile fashion. The scope was introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good condition. The articular surfaces looked good. The bicep also was in good condition. We went subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of bone anteriorly. Next we opened the AC joint through an anterosuperior portal. We ground off about 10 mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals. The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable condition. Code the procedure.


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## vivekveevin (Oct 12, 2020)

The patient presented for medial meniscal tear in left knee. Arthroscopy with partial medial meniscectomy left knee and arthroscopic picking (drilling pick holes) of the lateral femoral condyle left knee was performed. Code the procedure and diagnosis codes.


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## vivekveevin (Oct 12, 2020)

A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of the tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?


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## SharonCollachi (Oct 12, 2020)

vivekveevin said:


> A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of the tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?



These look like test questions.


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