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Alfaro33

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Coral Springs, Florida
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Would appreciate help coding this procedure. I'm thinking 44187?


Preoperative Diagnosis
Small-bowel obstruction

Postoperative Diagnosis
Same

Operation
Exploratory laparotomy and creation of ileostomy patient was brought to the or dressed and prepped in a sterile fashion after satisfactory sedation and intubation are precaution was taken for the head back and feet and midline incision was made 6 from the midline all the way down towards the pubic symphysis after entry into the peritoneum in the the small bowel was then followed from the ligament of Treitz all the way to the terminal ileum where we saw creeping fat and a stricture there and therefore decided to resect a portion and and the cecum and then creating an ileostomy for the safest approach. The LigaSure was then used to to cut through the mesentery and isolated vessels . The GI stapler was then used to cut through the small bowel and through descending portion the colon to resect the TI or terminal ileum. The area was irrigated multiple times to make sure there was no active bleeding. And creation of the ileostomy was then made with a Metzenbaum scissors and small bowel portion was then pulled through for the ileostomy. The midline incision was then closed with 0 the PDS looped PDS and interrupted 0 Prolene was then used to secure the midline incision. Colostomy was then matured with 3-0 Monocryl and the ostomy appliance was then placed patient tolerated skin stables then was then used to close incision site a patient tolerated procedure well taken recovery doctor Mike treating upper for patients Weber

Anesthesia
General

Technique
Exploratory laparotomy and creation of ileostomy

Estimated Blood Loss
Less than 30 cc

Findings
Creeping fat and stricture at the terminal ileum

Specimen(s)
Small bowel and terminal ileum

Complications
None
 
I would clarify a couple of portions of this operation with the surgeon, but will provide some initial guidance that might help. I wouldn't report 44187 because that code is for creation of an ileostomy alone through a laparoscopic approach. Here, the approach is an exploratory laparotomy (open abdominal incision) so we need to look at codes that don't reference a laparoscopic approach.

In addition to creating the ostomy, there is also removal of part of the bowel. This is where the questions back to the surgeon come in. In the body of the note, I understand him to say that they are removing part of the small intestine including the terminal ileum (the very end of the small intestine where it transitions to the colon). The specimens removed (small bowel and terminal ileum appear to align with that). If this is all that occurred (removal of part of the small intestine and creation of an ileostomy through an open approach), that would be a 44125. But then he says he uses a GI stapler to cut through the small bowel "and the descending portion of the colon." If that is the case, he would be removing part of the small bowel and the cecum of the colon on the other side of the terminal ileum. At that point, this is not as clean of a coding scenario. 44160 could be considered for removal of part of the small and large intestine including the terminal ileum but you would have to apply modifier 52 in my view because an ileocolostomy (anastomosis between remaining ileum and colon) is not performed. Then you would have to add on 44310 for creation of an ileostomy. Another question is right towards the end of the operative report after describing creation of an ileostomy, the surgeon says a "colostomy" is matured. The colostomy and the ileostomy are not the same from a coding perspective either. So again some conflicts here that should be clarified:

1) Was small bowel only or small bowel and colon removed?
2) Was an ileostomy or a colostomy created?

Once you know the answers to those questions, the coding should come into focus a little better. I hope that helps!

Kim
www.codingmastery.com
 
cpc2007 said:
I would clarify a couple of portions of this operation with the surgeon, but will provide some initial guidance that might help. I wouldn't report 44187 because that code is for creation of an ileostomy alone through a laparoscopic approach. Here, the approach is an exploratory laparotomy (open abdominal incision) so we need to look at codes that don't reference a laparoscopic approach.

In addition to creating the ostomy, there is also removal of part of the bowel. This is where the questions back to the surgeon come in. In the body of the note, I understand him to say that they are removing part of the small intestine including the terminal ileum (the very end of the small intestine where it transitions to the colon). The specimens removed (small bowel and terminal ileum appear to align with that). If this is all that occurred (removal of part of the small intestine and creation of an ileostomy through an open approach), that would be a 44125. But then he says he uses a GI stapler to cut through the small bowel "and the descending portion of the colon." If that is the case, he would be removing part of the small bowel and the cecum of the colon on the other side of the terminal ileum. At that point, this is not as clean of a coding scenario. 44160 could be considered for removal of part of the small and large intestine including the terminal ileum but you would have to apply modifier 52 in my view because an ileocolostomy (anastomosis between remaining ileum and colon) is not performed. Then you would have to add on 44310 for creation of an ileostomy. Another question is right towards the end of the operative report after describing creation of an ileostomy, the surgeon says a "colostomy" is matured. The colostomy and the ileostomy are not the same from a coding perspective either. So again some conflicts here that should be clarified:

1) Was small bowel only or small bowel and colon removed?
2) Was an ileostomy or a colostomy created?

Once you know the answers to those questions, the coding should come into focus a little better. I hope that helps!

Kim
www.codingmastery.com
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Thank you so much for your help!
 
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