# Need help coding this surgery!!!



## Lyndapolk (Nov 14, 2012)

PREOPERATIVE DIAGNOSIS:
Hidradenitis suppurativa, left buttock.

POSTOPERATIVE DIAGNOSIS:
Hidradenitis suppurativa, left buttock.

OPERATION PERFORMED:
Creation of laparoscopic sigmoid colon loop colostomy with radical resection of 
left buttock 25 x 13 cm hidradenitis suppurativa.  An application of 25 x 13 cm 
wound VAC.

OPERATIVE FINDINGS:
Within the abdomen, there were no findings of any significance.  Fortunately, 
the intra-abdominal viscera were not adhesed at all.  Access to the sigmoid 
colon was very nicely identified attached to the lateral gutter easily 
mobilized and brought to the abdominal wall for the creation of a loop 
colostomy.  With respect to the perianal skin, the hidradenitis was almost more 
severe in the buttock than that previously experienced in the lumbar back.  I 
had to resect skin almost 2 cm from the anal verge clearly necessitating the 
use of a wound VAC and the creation of a colostomy.

OPERATIVE PROCEDURE:
The patient was brought to the operative suite, placed supine on the operative 
table, induced under general anesthesia without difficulty.  After the 
induction of the anesthetic, the patient was properly positioned in the supine 
position, the abdomen prepped and draped and a pneumoperitoneum completed in 
the left upper quadrant off the costal margin where Veress needle was inserted, 
and the pneumoperitoneum initiated.  There, a 5 mm port was placed.  After the 
port, a 5 mm 30 degree scope was advanced and under direct visual guidance, a 
right lower quadrant 12 mm port was positioned and a right upper quadrant 5 mm 
port placed.  With all of these ports now in position, the patient was rotated 
to the right.  The adhesions of the sigmoid colon were sharply divided.  The 
colon was mobilized into the retroperitoneum.  It was then sufficiently lax 
that  it approached the abdominal wall quite easily.  At this point, spinal 
needle confirmed the location of the lateral rectus border or the lateral 
aspect rectus compartment.  At this point, the skin and subcutaneous tissue was 
resected down to fascia.  A longitudinal incision in the anterior rectus sheath 
completed.  The posterior rectus sheath entered.  The colostomy was brought 
through this.  Approximately 4.5 to 5 cm diameter incision with the loop 
brought up.  A bar was placed underneath the colostomy and sutured in position. 
 At this point, the pneumoperitoneum was deflated completely and the colostomy 
was matured.  Ports were removed.  The fascia of the 12 mm port was closed with 
0 Vicryl suture.  After the colostomy was matured a colostomy bag was placed 
and at this point the patient was then rolled onto an operative cart and then 
back on the operating table in the supine position for resection of the 
hidradenitis.  The skin of the buttock, lower back, and thighs were prepped 
with Betadine and draped sterilely, and the resection was completed.  A 25 x 13 
cm very irregularly marginated resection that included all of the hidradenitis 
in entirety.  It extended into the buttock and inferiorly down into the 
superior aspect of the medial thigh somewhat on the posterior aspect of this 
inner thigh.  The resection was then carried up the midline just within 2 cm of 
the anal verge and then up to the superior pilonidal region in which I had to 
cross the midline to the right side to completely resect the hidradenitis.  
With this resection down to fascia a sponge was placed.  The VAC dressings 
applied.  It held suction very nicely and the patient was taken to the recovery 
room having tolerated the operation without difficulty or complication.


The Doctor and I are not sure whether we should bill this as 44188 or unlisted code 44238 for the Colostomy and 11470 for the hidradenitis since he did not do a repair but attached a wound vac instead;   The codes I think should be 44188, 11470, 97606.   Please help!!


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## jewlz0879 (Nov 19, 2012)

I agree with 44188 and 11470. I'm not sure about the 97606. The documentation seems a little vague for 97606 but I don't have a lot of wound care exp.


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