# started off as exploratory lap.....



## herrera4 (Aug 10, 2011)

just when i think i get these........

  DETAILS OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position.  Following induction of general anesthesia, a Foley catheter was placed.  She was then prepped and draped in the usual sterile fashion using ChloraPrep.  The abdomen was entered through a long vertical midline incision and a large amount of free air issued forth.  There was gross fecal soilage noted.  The bowel was packed away and the liquid stool suctioned free.  Copious irrigation was carried out using multiple liters of warm saline solution followed by Ancef solution.  Glassman clamps were placed on the area of perforation in the cecum and after placement of a purse-string suture the cecum was decompressed of the remaining fecal material using a Poole sucker.  Sutures of silk were then used to close the areas of perforation to allow for manipulation of bowel without further spill.  There was spill noted throughout the abdominal cavity in both subphrenic spaces and both pericolic gutters of the pelvis.  Again this was copiously irrigated.  Palpation within the pelvis documented the area of intense inflammation and scarring from the patient's previous episodes of diverticulitis.  It was elected to transect the colon in the mid descending portion to allow for more facile dissection.  This was accomplished using the Endo-GIA using the blue load.  Mesenteric leaves were scored on the left side of the sigmoid colon.  This was carried down over the peritoneal reflection.  Using gentle blunt dissection we were able to gain the presacral plane to elevate the rectosigmoid from the sacrum.  There was intense inflammatory change along the right side of the colon in the area of the previous perforation making the dissection quite difficult.  The left ureters were aptly identified and were preserved.  I was eventually able to clear a space on the right side of the colonic mesentery to allow for transection of the rectum in an area of healthy tissue.  This was accomplished using the Endo-GIA with the purple load.  Once this was accomplished, the specimen was passed off the field and the area was irrigated copiously with Ancef and saline solution.  An Ancef pack was then placed in the pelvis.  Prior to packing, the corners of the Hartmann's pouch were marked with sutures of #1 PDS.  Attention was turned toward the right colon which as noted above was ischemic when compared to the mesenteric border from the distention and area of perforation.  The right colon was then mobilized to the hepatic flexure.  That was transected using the Endo-GIA using the blue load and the intervening mesentery was taken using clamps and ties.  The ileum was divided using the Endo-GIA.  The specimen was passed off the field and we were essentially left with a transected ileum and Hartmann's pouch encompassing the proximal transverse colon to the mid-descending colon.  At this point it was unsafe to perform anastomosis due to the amount of fecal soilage.  Accordingly the proximal transverse colon was secured to the ileum using two sutures of silk and the decision was made for the ileostomy in the right midabdomen.  The ileum was brought through the abdominal wall and was matured to the abdominal wall using multiple sutures of 3-0 Vicryl.  The mucous fistula was created in an identical fashion with eburnating sutures of 3-0 Vicryl in the left lower quadrant after excising a disk of skin and incising the fascia in a cruciate orientation.  Gloves were again changed.  The abdomen was again copiously irrigated with saline followed by Ancef solution, and the wound was closed with running #1 PDS double loop suture.  The wound was loosely approximated using staples and Vaseline gauze was placed over the mucous fistula.  Prior to closure, three Jackson-Pratt drains were placed through separate stab wounds.  The first was in the right subphrenic space, the second in the left subphrenic space and the third was placed in the pelvis.  All drains were secured with silk sutures.  Dry sterile dressings were applied.  The sponge, needle and instrument counts were reported as being correct x2, and the patient went back to the recovery room in stable condition

thank you for any help


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## surgonc87 (Aug 10, 2011)

i had to draw a picture for this one. see 44144....has 51 RVu for all that work which sounds right.

MS


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## herrera4 (Aug 10, 2011)

i had 44144 --but it just seemed like more,but no time was documented of course, thank you for the help


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## slpagel (Aug 10, 2011)

I to agree with 44144, but I also think your surgeon did a right collectomy as well or at least a partial you might want to check with him/her to verify.


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## herrera4 (Aug 10, 2011)

he did, this is where im getting confused. through my encoderpro -its bundled but im not sure if mod and what modifiers would apply.


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## surgonc87 (Aug 10, 2011)

yes it is confusing. We can play with codes all day such as 44140,44160,44143, 44144 any combination off...at the end of the day 44144 some how just explains it all. We don’t want to unbundle. If I was submitting this, I would not feel comfortable doing it any other way. You can also just mod 22 it with the correct documentation and time involved compared to a normal case.

.....Or better yet? use an unlisted code.
MS


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## herrera4 (Aug 12, 2011)

personally i might feel better with mod-22, because the procedure has a code-its just bundled. i will double check all doc for time. Thank you for the help


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