Wiki Help with Op Note

[Gemini18]

Pre and Postop Diagnoses:
1. Gunshot wound to the abdomen.
2. Open abdomen.
3. Intestinal discontinuity with stapled transverse colon.


Procedures:
1. Reopening of previous exploratory laparotomy.
2. A transverse handsewn end-to-end colon-to-colon anastomosis.
3. Loop ileostomy.
4. Abdominal wall closure.

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 100 mL


PROCEDURE: Patient was brought in the operating room. The wound VAC was removed. The abdomen was prepped and draped in the standard sterile fashion. Patient was already intubated.

Bilateral SCDs had already been placed as well as preoperative antibiotics. All 4 quadrants were irrigated and carefully inspected for injuries. No splenic laceration, there was no active bleeding from the liver. No additional injuries were found. There was no retroperitoneal hematoma or bleeding. Next, the 2 ends of the transverse colon were examined. They both appeared to have palpable blood supply. The fat was dissected free from the edge of the transverse colon and a transverse colocolo anastomosis was performed in 2 layers using an inner mucosa-to-mucosa running 2-0 Vicryl layer followed by an outer interrupted 2-0 nylon layer. This was performed in standard fashion. The intestine was free of tension, had good blood supply and the lumen was patent at the conclusion of the anastomosis.

Following the anastomosis, the small bowel was run from the ligament of Treitz to the terminal ileum. There appeared to be no abnormalities. A site was selected for the loop ileostomy just lateral to the umbilicus but centered over the rectus muscle. A circular incision was made to the skin and the anterior rectus muscle was incised. The rectus muscle itself was spread and the posterior rectus layer was then dissected free. Loop was pulled through this ostomy site and was proximal to the terminal ileum. The fascia was closed with running #1 looped PDS. The skin was reapproximated with staples and the loop ileostomy was matured with 3-0 Vicryl. A rubber catheter had been inserted as a bridge to keep the loop ileostomy elevated. An ostomy appliance was placed on the loop ileostomy. Dressing was placed on midline incision.

All counts were correct. The patient tolerated the procedure well. There were no complications.

I'm looking at codes: 49002, 44140, 44310 and maybe 10180.

Thanks a bunch!

 

[cmartin]

I agree w/ the 44310. For the colon, it would depend on whether the doctor you're billing for did the first surgery and what was billed then. It looks as though a partial colectomy was done and the ends were "clipped and dropped" to be dealt with at the 2nd look laparotomy (this one). If a 44140 was billed for the first surgery, then the anastomosis @ the 2nd surgery was included and nothing is billed for it now. When I have a case like that, if no other separately billable procedures take place, I just bill the 49002 for the 2nd op. If, like this one, you have another billable procedure (the ileostomy), then I bill that and not the 49002. If your doc didn't do the first surgery it gets more complicated, and might come under the 44130 for both (anastomosis of intestine, with or without cutaneous enterostomy), but if you have to use that, I'd go for a -22 modifier in this case.

 

[Gemini18]

Thanks CMARTIN -

To answer your question, Yes - he did do the first surgery. The procedures he did on the day prior to these were: Exploratory Lap; Hepatorrhaphy; Transverse Colon resection; Repair of gastrotomy x2; Mobilization of splenic flexure; Control of Transverse Colon mesenteric bleeding; EGD and Wound VAC placement.