# abdominal abscess and revision of hartmanns procedure



## lovetocode (Nov 16, 2011)

Please advise with proper codes.  Thanks in advance!!!

PREOPERATIVE DIAGNOSIS:
1. Abdominal wall abscess.
2. Peritoneal abscess with suspected Hartmann pouch disruption.

POSTOPERATIVE DIAGNOSIS:
1. Abdominal wall abscess.
2. Peritoneal abscess with Hartmann pouch disruption.

OPERATION PERFORMED:
1. Incision and drainage of abdominal wall abscess with removal of abdominal
    wall mesh and abdominal wall reconstruction using xenograft mesh.
2. Incision and drainage of peritoneum with large-bowel resection.

ANESTHESIA:
General plus local.

DESCRIPTION OF OPERATION:
The patient is on therapeutic IV antibiotic.  DVT prophylaxis consisted of
subcu heparin and pneumatic compression stockings.  The patient was placed
under general anesthesia after informed consent was obtained.  An orogastric
tube and Foley catheter were placed.  The abdomen was prepped and draped in the
usual fashion.  The left upper quadrant ostomy was left open.  The ostomy bag
was covered with an impervious plastic drape prior to the prep.  Next, an
oblique incision was made over the previous left groin incision.  Immediately
underneath the subcu tissue, there was foul-smelling anaerobic abscess
collection.  Aerobic and anaerobic cultures were obtained.  The area was
irrigated profusely with saline and Dakin solution.  The abscess cavity was in
continuity with existing chronic mesh.  This was taken down by careful sharp
dissection.  The cord structures were granulated and were left alone.  After
the mesh was removed, reconstruction was performed using Cook biologic
xenograft mesh and running PDS suture.  The wound was irrigated with additional
saline.  A Jackson-Pratt drain was placed over the mesh and brought out through
the left lower quadrant.  The wound was closed with running interrupted Vicryl.
The skin was left open.

Next, a midline incision was made in the lower abdomen.  The lower pelvis was
entered.  An abscess cavity was found in the left lower quadrant.  This was
also anaerobic in gross appearance.  Cultures of this were obtained and labeled
"peritoneum."  At the base of the abscess cavity, the Hartmann pouch was easily
mobilized and its staple line was seen to be disrupted.  Two inches of Hartmann
pouch was prepared and divided with the firing of a GIA stapler and oversewn
with Vicryl Lembert sutures.  The abdomen was irrigated with additional saline
and a drain was placed at this location of the abscess cavity, exiting the
abdomen in the right lower quadrant.  The abdominal wall fascia was closed with
running looped #1 PDS.  The subcutaneous tissues were reapproximated with
running Vicryl.  Portions of the wound were closed with staples.  Portions were
left open.  The open wounds in the left lower quadrant and the midline were
then packed with Betadine gauze.  The patient tolerated the procedure well.
All needle, sponge, and instrument counts were correct x2.


----------



## surgonc87 (Nov 16, 2011)

There are no CCI edits with this senario. And thats in order of greatest RVU.

49020
44604-m-51
15420-m-51
+11008
10180-m-51

MS


----------



## lovetocode (Nov 16, 2011)

Thanks I really appreciate your coding advice!


----------



## Lujanwj (Nov 16, 2011)

Previous coding is incorrect.  My suggested would be:

49020
11008
49568
10180

Previous code errors: 
44604 is an orraphy - Dr did resection with anas. 
44604 is bundled into 49020 as is 44140
15420 - is considered a prosthesis which is part of 49568 "or other prosthesis" 49568 is an add-on to 11008 per guidelines in CPT.  

Bests


----------



## surgonc87 (Nov 16, 2011)

Opps Encoderpro mislead me. There is an edit with 49020 & 44604, thereby, 49020 is more advantageous to report.

also your coding error pertains to (15420 - is considered a prosthesis which is part of 49568 "or other prosthesis" 49568 is an add-on to 11008 per guidelines in CPT. )--check the guidelines again.

Coding is ambiguous, so its not exactly correct to say others are wrong and you're always right.




Lujanwj said:


> Previous coding is incorrect.  My suggested would be:
> 
> 49020
> 11008
> ...


----------



## Grintwig (Nov 23, 2011)

What about:
49020
44604-59
15400
11008
10180

15420 is for face, scalp, neck, ears, orbits, genitalia, hands, feet, &/or multiple digits per CPT.
15400 is for trunk, arms, legs per CPT.
The closure for the Hartmann pouch to me does not seem to be directly related to the abscesses (there is no definite link made) and therefore can be coded with a -59 for separate procedure.
The modifiers would actually depend on what the previous abdominal procedure was and whether or not a global from it applied. The -59 would still apply to 44604 but might be a secondary modifier depending on whether or not the patient is in a global.


----------

