RainyDaze
Networker
I'm not sure about this, it probably is really easy but I'm having a brain freeze. My doc took a patient back to the OR two days after a lap partial colectomy w/anastomosis (44204). The second surgery consisted of a exploratory lap, transverse colectomy, and ileostomy with complex debridement of abdominal wall. I'm including the notes.
I'm going to use a modifier 78. But, my question is I'm trying to bill the colectomy and end ileostomy, but no anastomosis was performed. I'm not sure how to code this. And how about the debridement?
I opened his previous midline wound and extended it both cephaled and caudad. We entered the peritonel cavity with no untoward events. It emanated immediately succus and formed stool which was evacuated in all four quadrants. Over the course of the operation we irrigated with greater than 11 liters of fluid. After the inital approximately 650 ml of succus and tool were evacuated, I ran the bowel from the ligament of Treitz to the anastomotic area in question. There was a clear disruption in anastomosis. I then took down the mesentery of the small bowel with ligasure. I fired a GIA 75 stapler across the proximal end. I then cleared the mesentery of the transverse colon as well and fired a GIA 75 stapler across this. This was passed offas specimen and sent to path. We then began copious irrigation with approx. 11 liters of fulid paying due attention tot he subhepatic space, the splenic space, both colic gutters, and the deep pelvis. There was a diffuse peel across the small bowel, liver and variety of structures which were debrided as possible. When we reached clear effluent, I feed the small bowl adequely for ileostomy formation. We evacuated all fluid possible. We placed a kocher clamp along the lateral edge of the rectus muscle, elevating it. A circular incision was made. The subcutaneous fat was cleared. A cruciate incision was made through the rectus muscle and the small bowel was brought up for anticipated ileostomy. We then closed the midline with #1 looped PDS sutrues and it was packed with betadine sponges and protected with a 10-10 drape. I then matured the ostomy using interruped 4-0 vicryl sutures x8. An appliance was placed. We rinsed the midline wound again, placed kerlix. Prior to the placement of the wet-to-dry and foreclosure, I debrided the skin, subcutaneous fat, muscle, and fascia in the area of the previous wound as they appeared necrotic to clean edges. I then closed with looped PDS sutures as above, wet-to-dry, and ABD pads. The patient tolerated the procedure well.
I'm going to use a modifier 78. But, my question is I'm trying to bill the colectomy and end ileostomy, but no anastomosis was performed. I'm not sure how to code this. And how about the debridement?
I opened his previous midline wound and extended it both cephaled and caudad. We entered the peritonel cavity with no untoward events. It emanated immediately succus and formed stool which was evacuated in all four quadrants. Over the course of the operation we irrigated with greater than 11 liters of fluid. After the inital approximately 650 ml of succus and tool were evacuated, I ran the bowel from the ligament of Treitz to the anastomotic area in question. There was a clear disruption in anastomosis. I then took down the mesentery of the small bowel with ligasure. I fired a GIA 75 stapler across the proximal end. I then cleared the mesentery of the transverse colon as well and fired a GIA 75 stapler across this. This was passed offas specimen and sent to path. We then began copious irrigation with approx. 11 liters of fulid paying due attention tot he subhepatic space, the splenic space, both colic gutters, and the deep pelvis. There was a diffuse peel across the small bowel, liver and variety of structures which were debrided as possible. When we reached clear effluent, I feed the small bowl adequely for ileostomy formation. We evacuated all fluid possible. We placed a kocher clamp along the lateral edge of the rectus muscle, elevating it. A circular incision was made. The subcutaneous fat was cleared. A cruciate incision was made through the rectus muscle and the small bowel was brought up for anticipated ileostomy. We then closed the midline with #1 looped PDS sutrues and it was packed with betadine sponges and protected with a 10-10 drape. I then matured the ostomy using interruped 4-0 vicryl sutures x8. An appliance was placed. We rinsed the midline wound again, placed kerlix. Prior to the placement of the wet-to-dry and foreclosure, I debrided the skin, subcutaneous fat, muscle, and fascia in the area of the previous wound as they appeared necrotic to clean edges. I then closed with looped PDS sutures as above, wet-to-dry, and ABD pads. The patient tolerated the procedure well.