hedmiston
Contributor
I'm not sure how to code this case. I have 2 surgeons from the SAME division involved. Any help with the CPT & Dx codes would be greatly appreciated as I feel the codes they have provided are not completely accurate.
*Surgeon "A" billed CPT 44005, Dx K63.1 (intestinal perforation), K56.5 (intestinal adhes w/obst), K43.5 (parastomal hernia) & J44.9 (COPD)
Surgeon "A" Op report
Preop Dx: Intestinal perforation.
Postop Dx: Intense adhesions with intra-abdominal contamination, source unclear.
Indication for procedure:
Pt with COPD and a know incarcerated parastomal hernia after a sigmoid colectomy for perforated divertiulitis in 2013. Met with pt in 2015 when they had a partial SBO that resolved with nonoperative management. Pt presented to the hospital last month with an exacerbation of COPD, but was also found to have abdominal pain and developed a SBO associated with this as well. Pt initially improved, but then developed increasing pain, an elevated white count, and lethargy along with acute kidney injury manifested by an elevated creatinine. CT scan demonstrated free air. Pt comes now to the OR for exploration and determination of findings of intestinal perforation.
Findings:
Bilious contamination in areas of the abdomen. Entire lenth of the SB was run and no evidence of a perforation could be found. The stomach and duodenum were examined, no evidence of perforation could be identified.
Procedure:
Midline incision was made, careful dissection into the abdomen was undertaken. Four hours of adhesiolysis was necessary to free all the intestine and adhesions. Some adhesions were extraordinarily dense, in the course of this, 3 separate arteriotomies were made. These were stapled off and marked for future repair during the course of this operation; however, after this extensive adhesiolysis, the entire length of the SB was traced from the ligament of Treitz through to the terminal ileum and cecum. No evidence , other than our enterotomies, of a bowel perforation or injury was identified, although it is possible that one of these enterotomies predated and preceded our dissection. Also, in the course of this, the SB and LB were reduced out of the parastomal hernia. Thorough examination of the duodenum was undertake, seeking a site of perforation based on a perforated peptic ulcer; however, none was identified. At this point, Surgeon "B" assumed surgical care for the pt at my request. See their dictated note for repair of the resection of the enterotomies, repair of the small intestine, and repair of the parastomal hernia. Other than the unitentional enterotomies, there were no complications from the procedure.
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*Surgeon "B" billed CPT 44120-59, 44121-59, 44121-59 & 44346-59, Dx J44.9, K43.5, K56.69, K56.5 & K94.09
Surgeon "B" Op report
Postop Dx: Partial SBO thought to be due to parstomal hernia, intraperitoneal free air on CT scan, parastomal hernia.
Indication for procedure:
Pt has a complicated medical hx. Todays procedure was begun by Surgeon "A" that portion is dictated separately.
Description of Procedure: I entered the OR to relieve Surgeon "A". A complete LOA had been done with exploration of the abdomen. Three inadvertent SB injuries had been made during the difficult adhesiolysis and contents of the parastomal herniawere reduced as dictated by Surgeon "A". The 3 SB injuries were resected. After these 3 areas were resected, it was found that 2 of the injuries had been close enough to warrant removal of an intervening 16-cm segmentof SB, to minimize the number of enteric anastomoses. This segment was removed. The pelvis was irrigated and a few clips placed on small bleeding points on the peritoneum in the pelvis. The RT & LT gutter were irrigated w/o identification of any other injuries or abnormalities. The splenic flexure and descending colon were explored with no evidence of any inflammation or perforations.
Following this, 2 SB anastomosed were performed........
Following this, #2 Ethibond sutures in figures-of-8 uset to primarily close the parastomal hernia. Considering the length of time the pt was on the operating table, this was the most expeditious way to bring it into the procedure. A figure-of-8 was placed inferior to the stoma and tied in place. Three figures-of-8 of Ethibond were placed superior to the stoma, then tied down and produced a nice snug aperture.
Following this, warm irrigation was done again. Kockers were placed on the midline fascia, but the abdomen could not be closed in large part due to the significant amount of bowel edema related to the underlying disease process and time the pt had been in the OR. An ABThera appliance was placed over the viscera inside the peritoneal cavity. A sponge was placed atop the inital layer and the adhesive strips then placed onto the skin. Prior to this, the skin around the colostomy was closed over itself to seal the stoma closed to safely place the appliance. The appliance was placed and hooked up to the suction. Postoperative care will be provided by Surgeon "A".
My thoughts:
I feel they should bill as co-surgeons.
Not sure if Surgeon "B" should bill 3 resections or 2 resections.
Not sure what Dx code to bill for the 3 indavertent SB injuries.
Modifier 52 for Temp closure. Can modifier 22 be used also for extensive LOA? (Doesn't seem right reduced services with increased procedural services.)
Thank you in advance!
Hope
*Surgeon "A" billed CPT 44005, Dx K63.1 (intestinal perforation), K56.5 (intestinal adhes w/obst), K43.5 (parastomal hernia) & J44.9 (COPD)
Surgeon "A" Op report
Preop Dx: Intestinal perforation.
Postop Dx: Intense adhesions with intra-abdominal contamination, source unclear.
Indication for procedure:
Pt with COPD and a know incarcerated parastomal hernia after a sigmoid colectomy for perforated divertiulitis in 2013. Met with pt in 2015 when they had a partial SBO that resolved with nonoperative management. Pt presented to the hospital last month with an exacerbation of COPD, but was also found to have abdominal pain and developed a SBO associated with this as well. Pt initially improved, but then developed increasing pain, an elevated white count, and lethargy along with acute kidney injury manifested by an elevated creatinine. CT scan demonstrated free air. Pt comes now to the OR for exploration and determination of findings of intestinal perforation.
Findings:
Bilious contamination in areas of the abdomen. Entire lenth of the SB was run and no evidence of a perforation could be found. The stomach and duodenum were examined, no evidence of perforation could be identified.
Procedure:
Midline incision was made, careful dissection into the abdomen was undertaken. Four hours of adhesiolysis was necessary to free all the intestine and adhesions. Some adhesions were extraordinarily dense, in the course of this, 3 separate arteriotomies were made. These were stapled off and marked for future repair during the course of this operation; however, after this extensive adhesiolysis, the entire length of the SB was traced from the ligament of Treitz through to the terminal ileum and cecum. No evidence , other than our enterotomies, of a bowel perforation or injury was identified, although it is possible that one of these enterotomies predated and preceded our dissection. Also, in the course of this, the SB and LB were reduced out of the parastomal hernia. Thorough examination of the duodenum was undertake, seeking a site of perforation based on a perforated peptic ulcer; however, none was identified. At this point, Surgeon "B" assumed surgical care for the pt at my request. See their dictated note for repair of the resection of the enterotomies, repair of the small intestine, and repair of the parastomal hernia. Other than the unitentional enterotomies, there were no complications from the procedure.
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*Surgeon "B" billed CPT 44120-59, 44121-59, 44121-59 & 44346-59, Dx J44.9, K43.5, K56.69, K56.5 & K94.09
Surgeon "B" Op report
Postop Dx: Partial SBO thought to be due to parstomal hernia, intraperitoneal free air on CT scan, parastomal hernia.
Indication for procedure:
Pt has a complicated medical hx. Todays procedure was begun by Surgeon "A" that portion is dictated separately.
Description of Procedure: I entered the OR to relieve Surgeon "A". A complete LOA had been done with exploration of the abdomen. Three inadvertent SB injuries had been made during the difficult adhesiolysis and contents of the parastomal herniawere reduced as dictated by Surgeon "A". The 3 SB injuries were resected. After these 3 areas were resected, it was found that 2 of the injuries had been close enough to warrant removal of an intervening 16-cm segmentof SB, to minimize the number of enteric anastomoses. This segment was removed. The pelvis was irrigated and a few clips placed on small bleeding points on the peritoneum in the pelvis. The RT & LT gutter were irrigated w/o identification of any other injuries or abnormalities. The splenic flexure and descending colon were explored with no evidence of any inflammation or perforations.
Following this, 2 SB anastomosed were performed........
Following this, #2 Ethibond sutures in figures-of-8 uset to primarily close the parastomal hernia. Considering the length of time the pt was on the operating table, this was the most expeditious way to bring it into the procedure. A figure-of-8 was placed inferior to the stoma and tied in place. Three figures-of-8 of Ethibond were placed superior to the stoma, then tied down and produced a nice snug aperture.
Following this, warm irrigation was done again. Kockers were placed on the midline fascia, but the abdomen could not be closed in large part due to the significant amount of bowel edema related to the underlying disease process and time the pt had been in the OR. An ABThera appliance was placed over the viscera inside the peritoneal cavity. A sponge was placed atop the inital layer and the adhesive strips then placed onto the skin. Prior to this, the skin around the colostomy was closed over itself to seal the stoma closed to safely place the appliance. The appliance was placed and hooked up to the suction. Postoperative care will be provided by Surgeon "A".
My thoughts:
I feel they should bill as co-surgeons.
Not sure if Surgeon "B" should bill 3 resections or 2 resections.
Not sure what Dx code to bill for the 3 indavertent SB injuries.
Modifier 52 for Temp closure. Can modifier 22 be used also for extensive LOA? (Doesn't seem right reduced services with increased procedural services.)
Thank you in advance!
Hope
