General Surgery Coding Alert

Plus: Watch for unlisted service you can't afford to miss.Challenge yourself with this real-life complex fistula surgery to see if you can pinpoint the codes this documentation does -- and doesn't -- back up.Begin by Analyzing the Report ExcerptThe preliminary report states:Preoperative Diagnosis: Crohn's disease. Procedure Performed: Laparoscopic-assisted right hemicolectomy and fistulae take-down. Procedure Description: The surgeon established pneumoperitoneum and inserted the camera through a 10mm infraumbilical incision, identifying a ileocolic phlegmon in the right lower quadrant.The surgeon began by reflecting the small bowel from the pelvis into the upper abdomen, then freeing the terminal ileum from the right pelvic inlet sharply. The cecum was adherent to the anterior abdominal wall, and this was taken down sharply. The surgeon then worked from lateral to medial, taking the cecum and the right colon away from the lateral sidewall up toward the hepatic flexure.Realizing that the ileocolic phlegmon also involved multiple other loops of [...]