Wiki colon help!!!

[BABS37]

Hi! I need some help with a surgery- I can't tell if it was converted to an open procedure? Can someone help me??? I have 43236 and 49587 but not sure if the tatooing is included with the colectomy... haven't decided on a code for that procedure bc I don't know where to start with it.

- lap segmental colectomy with low pelvic anastomosis
- flexible sigmoidoscopy with tattooing of colon lesion
- repair of chronically incarcerated umbilical hernia

...he was positioned in the dorsal lithotomy. Prior to prepping the rectum, a flexible sigmoidoscope was inserted and maneuvered up to the previously identified lesion. This was by my estimate to measure between 20 and 25 cm from the anal verge. The distal margin of the lesion was marked with submucosal injection of blue ink. The scope was withdrawn. (43236- should this be included in the colectomy?)

The abdomen, perineum and rectum were prepped and draped sterilely. After prepping and draping the abdomen, an infraumbilical incision was made. Subcutaneous fat was divided. Chronically incarcerated umbilical hernia sac was identified and isolated at the facial level and then amputated, opening the peritoneal space. a 10 mm port was inserted. Pneumoperitoneum was obtained with carbon dioxide insufflation. Two 5mm right lower quadrant ports were inserted. The patient was positioned in trendelendburg and the tatooed mark on the colon was identified about 4-5cm above the peritoneal reflection idicating a distal sigmoid cancer. The colon was difficult to handle due to a large amount of epiploic fat and enormously thick mesentery as well as fat infiltration of the pelvic side walls creating a narrow pelvis. The lap mobilization was undertaken in a lateral to medial fashion bc of the challenges presented by the intraabdominal obesity. The white line of toldt was divided and the colon was mobilized medially. The left ureter was identified as well as the let gonadal vein which was left down. The colon was mobilized medially and the peritoneal reflection was divided extending around the anterior portion of the rectum. This was continued up the right side further mobilizing the colon. Once adequate mobilization was completed, it was felt that the pelvis was too narrow and the mesentery too thick to allow adequate division of the distal margin.

Additionally, there was difficulty identifying the right ureter bc of fatty tissue and it was elected to complete the procedure through a lower abdominal midline mini laparotomy. This was created and extended down through the fascia. The right ureter was identified by palpation and was clear of any dissection efforts as the remainder of the right side of the mesentery was mobilized. The proximal margin of division was chosen and divided with endo gia stapler. The inferior mesenteric artery pedicle was palpated and the mesenteric dissection was extended down towardsthe base of this with a harmonic scalpel. At a point just below the peritoneal reflection to allow adequate distal margin, the rectum was divided with a gia stapler. the remaining posterior mesenteric attachments were divided wtih the harmonic scalpel keeping both the ureters in view.

Following this, a proximal staple line was excised. A 2-0 prolene pursestring suture was placed and a 31mm eea stpler anvil was inserted and secured. A second 2-0 prolene suture was placed for added security. The colon on top of the anvil was defatted. The stapler was maneuvered up through the rectumand deployed through the center of the staple line. The anvil was attached, tightened down and fired. Nice cicumferential donuts were obtained times 2. The pelvis was filled with fluid and the anastomosis was examined... no leaks. All instrument counts were correct. The lower midline fascia was closed and the umbilical hernia defect was closed.

 

[kfantetti]

colon help

Hello BABS37,

I would code this as laparoscopic approach, 44207, even though there was a mini laparatomy done. If the OP report had stated something like "converted to open", or "wide mid-line incision", "the abdomen was desufflated" then I would use open approach. Mini laparatomies are used for specimen retrieval, too, with laparascopic colectomy procedures.

I would not use 49587, it is bundled to the colectomy. The NCCI edit is in Chpt. VI, E, 4.- "If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessesary."

In regard to the tatooing, it does not bundle to the colectomy, would use 45335, flex sigmoidoscopy with sub mucosal injection. I have not seen this done during the same operative episode as the colectomy, in my experience, it is done during an earlier visit, either by the Gastroenterologist, or the General Surgeon during the endoscopy, and the lesion/site marked for later surgical removal, so billing together is not an issue.

Hope this helps you.

 

[cwpierce]

Ok Babs,

Let's see if we can take this one step at a time. 43236 is not the code to be using for the sigmoidoscopy with tattooing. The approach on code 43236 is through the mouth and down the esophagus. You need to look at a code where the approach is through the exhaust pipe. You want to look at 45381 and I think you will find that it is the more applicable code and yes, according to NCCI Edits you are allowed to bill the tattooing with your low pelvis anastamosis colectomy.

Now let's examine the low pelvis colectomy. The physician started the procedure with a laparoscopic approach but as you read down in the 3rd paragraph of his op note he converted to a mini laparotomy so we just went from 44207 to 44145. Please don't forget to include V64.41 as a Dx to support this conversion. I venture to say that you have enough information here to possibly warrant a -22 modifier as well.

Finally, the tricky part... the umbilical hernia repair. 49587 looks like a fine code to use had the physician actually dictated the repair of the umbilical hernia defect but as you see he/she has given us just a "one-liner" to cover the repair. I would ask the physician to add an addendum with dictation stating how the hernia was incarcerated. The mention of it being incarcerated up in the Procedures portion of the op note, in my opinion, is just not enough. We need supporting documentation and keep in mind that this hernia repair will probably unbundle to the colectomy so we may need to apply a modifer -59 as it is allowable.

Hope this helped.