# What CPT code for this?



## jdibble (Dec 30, 2015)

My surgeon did a subtotal gastrectomy with Roux-en-y and then had to take the patient back to surgery 3 days later for a duodenal stump leak. I am not sure what CPT code to use. I was looking at 43840-78 but am not sure that this is what was done. I was thinking of going the unlisted route, 43999-78, but wanted some opinions or suggestions as to if there is a better code out there. 

Any help would be greatly appreciated! The following is the note:

POSTOPERATIVE DIAGNOSIS:  Duodenal stump leak.

OPERATION:  Repair of duodenal stump leak.

SPECIMEN:  Partial pylorus and infrapyloric tissue.

FINDINGS:  Edematous pylorus and duodenal stump with some bile staining on part
of the incision line.  It was partially resected and reanastomosed in 2 layers
and reinforced with the falciform ligament sewn on it.

INDICATIONS FOR PROCEDURE:  The patient is a 61-year-old man who had undergone
subtotal gastrectomy on _______ and had been doing well until he was found to
have some bile drainage from his Blake drain.  He was evaluated with a CT scan
which did not reveal any kind of a leak, however he became tachycardic and left
shift with low grade fever.  It was decided that he would need to be explored.
The possible risks, benefits, and complications of reexploration were discussed.
The patient and his brother understood and agreed to proceed with surgery.

DESCRIPTION OF PROCEDURE:  The patient was brought to the OR on ______ and
placed on the table in supine position.  After adequate general anesthesia he
was prepped and draped in a sterile fashion.  The staples were taken out prior
to surgery.  The midline incision was opened and inspection was undertaken.
There was noted to be a small collection of bile right as we entered the
abdomen.  This was suctioned out and then inspection was undertaken all around
the area.  Once the area of the pyloric/duodenal stump was identified, there was
noted to be some bile staining on part of the incision site.  However,
inspection taken behind it did not reveal any further bile leakage or other bile
staining.  Inspection was undertaken to the Roux-en-Y or gastrojejunostomy
anastomosis and there did not appear to be any leakage or drainage in this area.
No bile staining.  Attention was then directed back to the duodenal stump leak
and inspection around by the liver, the common bile duct, and the duodenal sweep
was undertaken and no other areas of leakage were noted.  At this point, it was
decided to try to repair this area.  It was noted to be less edematous than it
had been at the first surgery so attempts were made to dissect it out further
and the infrapyloric tissue that was also still there, more of that was taken.
A TA-60 was attempted to be taken across it, however it was again too edematous
so only partially stabled.  It ended up having to be repaired in 2 layers with a
3-0 Vicryl stitch to sew up the mucosa and submucosa and then 2-0 silk Lembert
stitches were reinforced over the outer serosa layer.  Once this was repaired,
the falciform ligament was taken down and swung over to the anastomosis and sewn
down on either side with 3-0 silk stitches.

Inspection was then taken into the belly down in the pelvis to suction out any
bile.  No bile was noted.  Again, inspection was undertaken of the Roux-en-Y
anastomosis and it was intact with no leakage or other findings.  The belly was
then irrigated with saline and saline was suctioned out.  Then the Blake drain
was placed back around the duodenal stump site and across to the
gastrojejunostomy anastomosis.  The midline fascia was closed with a running #1
looped PDS and then the subcutaneous tissue was irrigated with saline.  The skin
was approximated with staples.  The patient tolerated the procedure well and was
taken to the recovery room in stable condition.  All counts correct at the end
of the case.

Thanks,
Jodi


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## nrichard (Dec 30, 2015)

*Look at 49002 with modifier 78*

This is for reopening of a recent laparotomy site. This code's purpose is for when a surgeon needs to go back in and repair an structures previously operated on.


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## jdibble (Dec 31, 2015)

nrichard said:


> This is for reopening of a recent laparotomy site. This code's purpose is for when a surgeon needs to go back in and repair an structures previously operated on.



I looked into the use of this code and I don't think this would be appropriate as the surgeon did a more definitive procedure than what 49002 describes. I found the following information from the American College of Surgeons -  http://bulletin.facs.org/2013/08/coding-for-damage-control-surgery/:

"CPT code 49002 describes a procedure that may be used in instances of trauma, sepsis, or ischemic bowel surgery to examine the progress of healing, check on the integrity of an anastomosis, detect missed injuries or further ischemia, and irrigate the abdomen. Remember, if a more extensive abdominal procedure is required in the same operative session as the re-exploration of the laparotomy, such as CPT code 44120 (enterectomy, resection of small intestine; single resection and anastomosis), then re-exploration of the laparotomy (49002) should not be used, as it is considered inherent to the more extensive procedure and is not separately reportable."

In my case the surgeon found an issue and repaired it, so I think I still need to look at another CPT code.  

Thanks for your input - that was helpful.


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## mzkandyd (Jan 3, 2016)

Yes, unlisted, comparison to a sutures of a gastric ulcer.


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