jpelfrey00
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Any CPT coding help with this would be greatly appreciated. General Surgery is still a little out of my comfort zone in coding.
Patient had sigmoid colectomy 10 days prior and returned to ER with blood per rectum and abdominal pain. CT showed leak with contamination left of descending colon
Vertical incision was made through prior incision and the abdominal cavity was entered. The left colon was retracted medially and a collection was encountered containing fluid and fecal material. This material was evacuated and the region was irrigated. I did not identify anastomosis. A 10 flat Jackson-Pratt drain was place in that space and brought out through the left lateral abdominal wall. it was secured to the skin with 2-0 Prolene.
A segment of ileum that would easily reach up to the abdominal wall without tension was identified. A twill tape was placed through the mesentery and a circular incision was created to the right of midline. SubQ fat was incised with electrocautery as was the anterior rectus fascia. Rectus muscle was spread bilaterally and posterior fascia was incised vertically. The ileum was externalized and held in place with a catheter serving as a stoma rod. The abdomen was irrigated with saline and closed with running #1 Vicryl suture. SubQ tissue was irrigated with saline and closed with 3-0 Vicryl. Skin staples were applied. The ileostomy was matured in Brooke fashion with interrupted 3-0 chromic sutures. Stoma rod was secured in place with 2-0 Prolene suture. Patient was extubated and taken to recovery in stable condition.
Patient had sigmoid colectomy 10 days prior and returned to ER with blood per rectum and abdominal pain. CT showed leak with contamination left of descending colon
Vertical incision was made through prior incision and the abdominal cavity was entered. The left colon was retracted medially and a collection was encountered containing fluid and fecal material. This material was evacuated and the region was irrigated. I did not identify anastomosis. A 10 flat Jackson-Pratt drain was place in that space and brought out through the left lateral abdominal wall. it was secured to the skin with 2-0 Prolene.
A segment of ileum that would easily reach up to the abdominal wall without tension was identified. A twill tape was placed through the mesentery and a circular incision was created to the right of midline. SubQ fat was incised with electrocautery as was the anterior rectus fascia. Rectus muscle was spread bilaterally and posterior fascia was incised vertically. The ileum was externalized and held in place with a catheter serving as a stoma rod. The abdomen was irrigated with saline and closed with running #1 Vicryl suture. SubQ tissue was irrigated with saline and closed with 3-0 Vicryl. Skin staples were applied. The ileostomy was matured in Brooke fashion with interrupted 3-0 chromic sutures. Stoma rod was secured in place with 2-0 Prolene suture. Patient was extubated and taken to recovery in stable condition.