mfournier
Networker
Hello Fellow Coders:
Would someone be able to brake this down for me? 43246, 44120 and 44310 with modifier 78 were billed and the auditing company stated the record does not support any of the services billed?
So, was wondering if someone can shade some light on this surgical case.
Any guidelines or explanation would be greatly appreciated.
I have posted the op note below:
Preoperative diagnosis: Open abdomen, intestinal discontinuity
Postoperative diagnosis: #1 persistent, but improved, patchy ischemia of the small intestine
Procedure: Exploratory laparotomy, abdominal washout, partial resection of small intestine and transverse colon, enterorrhaphy, end ileostomy, gastrostomy
Specimen: Portion of ileum, ileocolonic anastomosis, portion of transverse colon
Findings: Persistent but improved patchy ischemia in the small intestine. One area of concern oversewn with interrupted 3-0 Vicryl Lembert sutures
I have proposed exploratory laparotomy, possible bowel resection, gastrostomy, and abdominal washout.
Operative technique: After obtaining adequate informed signed the patient was taken the operating theater. He was placed in supine position operative table with arms outstretched on padded arm boards. Safety belt was placed across the lower extremities. The outer components of the ABThera open abdominal closure device were removed. The abdomen was prepped and draped in standard sterile surgical fashion. The inner components of the ABThera removed and passed off the field. The abdomen was entered and fluid was suctioned from the field. The involved area of the small intestine from the prior operation was delivered up and into the field and carefully inspected. Continued patchy areas of partial ischemia were noted. In 1 such area, a enterorrhaphy was performed with interrupted 3-0 Vicryl Lembert sutures to imbricate this area of concern. The other areas appeared otherwise viable. The distal 20 cm of ileum leading into the ileocolonic anastomosis continued to have evidence of patchy ischemia, and although there was no apparent leakage at the ileocolonic staple line, after inspection of this area, I determined it would be prudent to resect this, as well as the anastomosis to avoid additional risk of leakage in the near term in favor of a long Hartman's pouch decompressing distally. Distal to the anastomosis along the transverse colon a window was made in the mesentery and this mesenteric window was extended with LigaSure. The GIA 75 stapler was directed across this window, closed and fired. The mesentery to the ileocolonic anastomosis was then taken. This freed up the specimen which was passed off the field labeled portion of ileum, ileocolonic anastomosis with portion of transverse colon. I turned my attention back to the cut edge of the mesentery to the terminal extent of the ileum and determine the last several centimeters here I would need to be resected back to viable tissue as well for the purpose of exteriorization and ostomy. An ostomy aperture was developed 2 fingerbreadths superior and lateral to the umbilicus by excising the skin disc, dissecting through subcutaneous tissues to the rectus muscle anterior fascia which was divided in a cruciate manner. The muscle belly was then bluntly divided by spreading with clamps, and the posterior sheath was incised vertically with electrocautery pencil with my hand on the abdominal side to protect the underlying abdominal contents. When the ostomy aperture was developed an extra small Alexis wound retractor was directed through it. We now turned attention to placement of a gastrostomy tube. The stomach was delivered down into the field with use of Babcock clamps. Lateral to the upper portion of the upper midline incision a small skin incision was made with a #15 blade. A 0 Vicryl pursestring suture was placed in the stomach at the proposed site of tube placement. On either side of this pursestring suture 0 silk stay sutures were placed for fixation to the abdominal wall. Once the sutures were in place I delivered a 22 French MIC gastrostomy tube through the abdominal wall into the abdomen. The balloon was tested and held air for several minutes. The balloon was then collapsed and a gastrotomy was made with the electrocautery pencil and the gastrostomy tube was delivered into the stomach under direct visualization. At this point the nasogastric tube had been removed. With the tube in the stomach the balloon was inflated and the tube passed freely back-and-forth through the gastric wall. The pursestring suture was now secured snugly around the tube itself. To motility was again tested and the tube spun easily in place and move forward and backwards. With the balloon now seated just underneath the pursestring suture the 0 silk sutures were used to secure the stomach to the abdominal wall. When these fixation sutures were secured we turned our attention back to the ostomy aperture. The small intestine was delivered through the abdominal wall. We then closed the midline fascia using #1 looped PDS 1 begun superiorly, 1 begun inferiorly and the 2 joint just above the umbilicus. The end ileostomy was matured with interrupted 3-0 Vicryl sutures achieving 1-1/2 cm of Brooke eversion. An ostomy appliance was cut to fit. A black sponge wound VAC was then placed on the midline and placed to the KCI vacuum system in the usual manner. At this point the procedure was complete.
Thereafter anesthesia was reversed, the patient was extubated, and patient was taken to intensive care unit having tolerated procedure well no apparent complication. All sponge instrument and sharp counts were reported as correct by the operating staff. I was present and scrubbed for the entire case as detailed.
Would someone be able to brake this down for me? 43246, 44120 and 44310 with modifier 78 were billed and the auditing company stated the record does not support any of the services billed?
So, was wondering if someone can shade some light on this surgical case.
Any guidelines or explanation would be greatly appreciated.
I have posted the op note below:
Preoperative diagnosis: Open abdomen, intestinal discontinuity
Postoperative diagnosis: #1 persistent, but improved, patchy ischemia of the small intestine
Procedure: Exploratory laparotomy, abdominal washout, partial resection of small intestine and transverse colon, enterorrhaphy, end ileostomy, gastrostomy
Specimen: Portion of ileum, ileocolonic anastomosis, portion of transverse colon
Findings: Persistent but improved patchy ischemia in the small intestine. One area of concern oversewn with interrupted 3-0 Vicryl Lembert sutures
I have proposed exploratory laparotomy, possible bowel resection, gastrostomy, and abdominal washout.
Operative technique: After obtaining adequate informed signed the patient was taken the operating theater. He was placed in supine position operative table with arms outstretched on padded arm boards. Safety belt was placed across the lower extremities. The outer components of the ABThera open abdominal closure device were removed. The abdomen was prepped and draped in standard sterile surgical fashion. The inner components of the ABThera removed and passed off the field. The abdomen was entered and fluid was suctioned from the field. The involved area of the small intestine from the prior operation was delivered up and into the field and carefully inspected. Continued patchy areas of partial ischemia were noted. In 1 such area, a enterorrhaphy was performed with interrupted 3-0 Vicryl Lembert sutures to imbricate this area of concern. The other areas appeared otherwise viable. The distal 20 cm of ileum leading into the ileocolonic anastomosis continued to have evidence of patchy ischemia, and although there was no apparent leakage at the ileocolonic staple line, after inspection of this area, I determined it would be prudent to resect this, as well as the anastomosis to avoid additional risk of leakage in the near term in favor of a long Hartman's pouch decompressing distally. Distal to the anastomosis along the transverse colon a window was made in the mesentery and this mesenteric window was extended with LigaSure. The GIA 75 stapler was directed across this window, closed and fired. The mesentery to the ileocolonic anastomosis was then taken. This freed up the specimen which was passed off the field labeled portion of ileum, ileocolonic anastomosis with portion of transverse colon. I turned my attention back to the cut edge of the mesentery to the terminal extent of the ileum and determine the last several centimeters here I would need to be resected back to viable tissue as well for the purpose of exteriorization and ostomy. An ostomy aperture was developed 2 fingerbreadths superior and lateral to the umbilicus by excising the skin disc, dissecting through subcutaneous tissues to the rectus muscle anterior fascia which was divided in a cruciate manner. The muscle belly was then bluntly divided by spreading with clamps, and the posterior sheath was incised vertically with electrocautery pencil with my hand on the abdominal side to protect the underlying abdominal contents. When the ostomy aperture was developed an extra small Alexis wound retractor was directed through it. We now turned attention to placement of a gastrostomy tube. The stomach was delivered down into the field with use of Babcock clamps. Lateral to the upper portion of the upper midline incision a small skin incision was made with a #15 blade. A 0 Vicryl pursestring suture was placed in the stomach at the proposed site of tube placement. On either side of this pursestring suture 0 silk stay sutures were placed for fixation to the abdominal wall. Once the sutures were in place I delivered a 22 French MIC gastrostomy tube through the abdominal wall into the abdomen. The balloon was tested and held air for several minutes. The balloon was then collapsed and a gastrotomy was made with the electrocautery pencil and the gastrostomy tube was delivered into the stomach under direct visualization. At this point the nasogastric tube had been removed. With the tube in the stomach the balloon was inflated and the tube passed freely back-and-forth through the gastric wall. The pursestring suture was now secured snugly around the tube itself. To motility was again tested and the tube spun easily in place and move forward and backwards. With the balloon now seated just underneath the pursestring suture the 0 silk sutures were used to secure the stomach to the abdominal wall. When these fixation sutures were secured we turned our attention back to the ostomy aperture. The small intestine was delivered through the abdominal wall. We then closed the midline fascia using #1 looped PDS 1 begun superiorly, 1 begun inferiorly and the 2 joint just above the umbilicus. The end ileostomy was matured with interrupted 3-0 Vicryl sutures achieving 1-1/2 cm of Brooke eversion. An ostomy appliance was cut to fit. A black sponge wound VAC was then placed on the midline and placed to the KCI vacuum system in the usual manner. At this point the procedure was complete.
Thereafter anesthesia was reversed, the patient was extubated, and patient was taken to intensive care unit having tolerated procedure well no apparent complication. All sponge instrument and sharp counts were reported as correct by the operating staff. I was present and scrubbed for the entire case as detailed.