stacigadsby
Contributor
Hi everyone, and thanks in advance. I've been recently thrown into surgery coding which I'm almost completely unfamiliar with. I try to look up codes for each part of the procedure and then check for edits.
This case is a Laparoscopic sigmoid colectomy with primary anastomosis, extensive lysis of adhesions, debridement of pericolonic abscess and debridement and closure of colo-vesical fistula.
I've got 44204 for the colectomy/anastomosis with a -22 for the adhesions, but I don't know what (if anything) to use for the debridement and closure.
are these just bundled into the colectomy ?
OPERATIVE FINDINGS:
The sigmoid colon was tightly adherent to the left lower quadrant abdominal wall. There were
obvious extensive diverticula throughout the sigmoid and descending colon. The colon was
also plastered to the right dome of the bladder which entered into a pericolonic abscess
containing thick light yellow pus. The fistulous communication was at the site of the
abscess adjacent to the right dome of the bladder. Once debrided, there was a 1.5 cm opening
in the bladder wall, which was closed primarily. Additionally, there were adhesions of small
bowel within the pelvis as well as some omental adhesions which needed to be taken down such
that omental flap could be created at the end of the case.
PROCEDURE IN DETAIL:
The patient was taken to the Operating Room and administered general endotracheal anesthesia.
The abdomen was prepped and draped in the supine position with legs in the Allen stirrups and
low lithotomy position. The abdomen was prepped and then the perineum was prepped in the
usual manner. After draping, then an infraumbilical incision 6 cm in length was ma.de and
dissected into the abdominal cavity. At this site, the Dextrus hand port device was
installed and. then hand-assisted laparoscopy was utilized for the remainder of the case.
Additional trocars placed included a right lower quadrant 11 and 12 mm trocar . All the above
findings were photographed. The dissection began by first mobilizing this attached omentum
in the area of left lower quadrant . The sigmoid colon was then carefully inspected and then
there was a very obvious tight fusion of the sigmoid colon to the left lower quadrant
anterior abdominal wall extending into the pelvis. This was taken down with a combination of
blunt and electrocautery dissection, eventually detaching the firm and woody induration in
this area. The colon was eventually mobilized away from the abdominal wall, entering an
abscesses containing whitish pus. This was debrided, suctioned, and then the remainder of
the colon was detached from the left lower quadrant. The attachment of the abscess cavity to
the dome of the bladder revealed erosion into the bladder, and then once detached, the
bladder mucosa could be seen with the debridement of the abscess . These findings were
photographed .
Attention was turned back to the sigmoid colon where the colon was mobilized medially
identifying the left ureter and then mobilizing the descending colon medially, dividing the
peritoneal reflection. Distally, the rectum was advanced out of the pelvis and then a
laparoscopic sigmoid colectomy was performed by first finding the distal margin at the
rectosigmoid junction which was free of diverticula and divided using the Ethicon Endo-GIA
stapler . The mesentery of the sigmoid colon was foreshortened, however , divided using the
GIA stapler. The proximal margin was identified and then the freed portion of sigmoid colon
was removed from the abdomen and exteriorized via the handoscopy port . At the previously
selected proximal margin site, the bowel was divided between Glassman clamps and then the 2 9
mm EEA anvil was installed in the proximal stump using a 2-0 Prolene pursestring. The
mesenteric attachments which were remaining for the sigmoid colon were divided between clamps
and 2-0 Vicryl ties.
The rectum was then dilated using the EEA dilators . There were some benign strictures which
were broken down during this dilation process and then the stapler was introduced per rectum
and then the anastomosis was created . The anastomosis as well as the mesenteric defects was
then supported using multiple interrupted 2-0 Ethibond sutures .
Attention was then turned back to the right dome of the bladder where the fistula site was
debrided, excising the eroded area of mucosa into the bladder, was debrided back to healthy
tissue resulting in about 1.5 cm opening into the bladder. The inside of the bladder could
be visualized and also the trigone was palpated and not in the area of the repair. The
repair was done by transversely approximating the bladder wall in 2 layers initially using
multiple interrupted inverting interrupted sutures of 3-0 PDS . A second row of Lembert type
sutures were used to support the closure . After the abdomen was thoroughly irrigated with
multiple liters of warm saline and all the gutters were aspirated, the greater omentum was
mobilized into the pelvis and then sutured such that there was an interposition between the
bladder repair and the colectomy anastomosis . This greater omentum was affixed in this
position using interrupted 2-0 Ethibond sutures. A single Jackson-Pratt drain was then
installed into the pelvis and exited the right lower quadrant trocar site. The 11 and 12 mm
trocar sites were closed and was inside the abdomen using 0 Vicryl suture and then the
handoscopy port was closed in layers using continuous 0 Vicryl suture followed by a
continuous #1 PDS suture and then all skin incisions were approximated using subcuticular
suture of 3-0 Vicryl .
Thanks for any help you can provide.
This case is a Laparoscopic sigmoid colectomy with primary anastomosis, extensive lysis of adhesions, debridement of pericolonic abscess and debridement and closure of colo-vesical fistula.
I've got 44204 for the colectomy/anastomosis with a -22 for the adhesions, but I don't know what (if anything) to use for the debridement and closure.
are these just bundled into the colectomy ?
OPERATIVE FINDINGS:
The sigmoid colon was tightly adherent to the left lower quadrant abdominal wall. There were
obvious extensive diverticula throughout the sigmoid and descending colon. The colon was
also plastered to the right dome of the bladder which entered into a pericolonic abscess
containing thick light yellow pus. The fistulous communication was at the site of the
abscess adjacent to the right dome of the bladder. Once debrided, there was a 1.5 cm opening
in the bladder wall, which was closed primarily. Additionally, there were adhesions of small
bowel within the pelvis as well as some omental adhesions which needed to be taken down such
that omental flap could be created at the end of the case.
PROCEDURE IN DETAIL:
The patient was taken to the Operating Room and administered general endotracheal anesthesia.
The abdomen was prepped and draped in the supine position with legs in the Allen stirrups and
low lithotomy position. The abdomen was prepped and then the perineum was prepped in the
usual manner. After draping, then an infraumbilical incision 6 cm in length was ma.de and
dissected into the abdominal cavity. At this site, the Dextrus hand port device was
installed and. then hand-assisted laparoscopy was utilized for the remainder of the case.
Additional trocars placed included a right lower quadrant 11 and 12 mm trocar . All the above
findings were photographed. The dissection began by first mobilizing this attached omentum
in the area of left lower quadrant . The sigmoid colon was then carefully inspected and then
there was a very obvious tight fusion of the sigmoid colon to the left lower quadrant
anterior abdominal wall extending into the pelvis. This was taken down with a combination of
blunt and electrocautery dissection, eventually detaching the firm and woody induration in
this area. The colon was eventually mobilized away from the abdominal wall, entering an
abscesses containing whitish pus. This was debrided, suctioned, and then the remainder of
the colon was detached from the left lower quadrant. The attachment of the abscess cavity to
the dome of the bladder revealed erosion into the bladder, and then once detached, the
bladder mucosa could be seen with the debridement of the abscess . These findings were
photographed .
Attention was turned back to the sigmoid colon where the colon was mobilized medially
identifying the left ureter and then mobilizing the descending colon medially, dividing the
peritoneal reflection. Distally, the rectum was advanced out of the pelvis and then a
laparoscopic sigmoid colectomy was performed by first finding the distal margin at the
rectosigmoid junction which was free of diverticula and divided using the Ethicon Endo-GIA
stapler . The mesentery of the sigmoid colon was foreshortened, however , divided using the
GIA stapler. The proximal margin was identified and then the freed portion of sigmoid colon
was removed from the abdomen and exteriorized via the handoscopy port . At the previously
selected proximal margin site, the bowel was divided between Glassman clamps and then the 2 9
mm EEA anvil was installed in the proximal stump using a 2-0 Prolene pursestring. The
mesenteric attachments which were remaining for the sigmoid colon were divided between clamps
and 2-0 Vicryl ties.
The rectum was then dilated using the EEA dilators . There were some benign strictures which
were broken down during this dilation process and then the stapler was introduced per rectum
and then the anastomosis was created . The anastomosis as well as the mesenteric defects was
then supported using multiple interrupted 2-0 Ethibond sutures .
Attention was then turned back to the right dome of the bladder where the fistula site was
debrided, excising the eroded area of mucosa into the bladder, was debrided back to healthy
tissue resulting in about 1.5 cm opening into the bladder. The inside of the bladder could
be visualized and also the trigone was palpated and not in the area of the repair. The
repair was done by transversely approximating the bladder wall in 2 layers initially using
multiple interrupted inverting interrupted sutures of 3-0 PDS . A second row of Lembert type
sutures were used to support the closure . After the abdomen was thoroughly irrigated with
multiple liters of warm saline and all the gutters were aspirated, the greater omentum was
mobilized into the pelvis and then sutured such that there was an interposition between the
bladder repair and the colectomy anastomosis . This greater omentum was affixed in this
position using interrupted 2-0 Ethibond sutures. A single Jackson-Pratt drain was then
installed into the pelvis and exited the right lower quadrant trocar site. The 11 and 12 mm
trocar sites were closed and was inside the abdomen using 0 Vicryl suture and then the
handoscopy port was closed in layers using continuous 0 Vicryl suture followed by a
continuous #1 PDS suture and then all skin incisions were approximated using subcuticular
suture of 3-0 Vicryl .
Thanks for any help you can provide.