maljdcpc
Networker
Need help coding the following procedure. Not sure if coding this right so any input/corrections would be greatly appreciated. Not sure if I could add 22 modifier on 44227 for lysis of adhesions? I didn't get any NCCI edits for flex sig 45330- however, is it right to code it in this case?
A time-out was performed. An incision was made around the colostomy.
Dissection continued down to the fascia. The fascia was circumferentially
mobilized until the significant portion of the left colon could be mobilized
through the wound. The colostomy remnant was resected. A pursestring suture
was placed around the cut end of colon, the anvil 29 EEA stapler was placed
in anticipation of an end-end anastomosis. There was occasional
diverticulosis, that was seen, which had not been seen on the colonoscopy.
The bowel was placed back into the abdomen and a Gelpoint wound protector
was placed. The top of the Gelpoint was also inserted. Pneumoperitoneum was
easily achieved. There were significant adhesions of omentum to the anterior
abdominal wall. A 5 mm port was placed in the left lower quadrant. These
adhesions were taken down using the Harmonic scalpel.
A 10 mm port was placed in the right lower quadrant, a 5 mm port was placed
in the right upper quadrant. The left colon could easily be seen. It was
retracted medially. The white line of Toldt was incised. The entire left
colon and splenic flexure were carefully mobilized. There is a small
capsular tear in the spleen that was easily controlled with fibrillar.
Dissection was now continued in a retroperitoneal fashion up under the
inferior mesenteric artery. This was circumferentially cleaned, divided with
an Echelon load with a white load. In addition, the IMV was also identified
and circumferentially clean and also divided with an Echelon load with a
white load. The vessels had to be taken in order to ensure adequate length
for reach for the anastomosis of the left colon.
With this accomplished, attention was now paid to the pelvis. The Hartmann
stump could easily be seen. The small bowel was lifted out of the pelvis.
The presacral space was entered. Dissection was continued to rest for short
distance until soft healthy, pliable area of rectum was identified just
above the peritoneal reflection. The mesorectum in this region was divided
with Harmonic scalpel. The rectum was divided with an Echelon load with a
gold load. The Hartmanns pouch remnant was then brought out through the
left lower quadrant ostomy site through the wound protector and sent to
pathology along with the colostomy remnant to Pathology for routine
processing.
A 29 EEA stapler was now inserted into the rectum until the end of the
stapler was flushed with the end of staple line. The trocars advanced. The
anvil of the proximal bowel was engaged onto the trocar. After ensuring
correct orientation, the stapler was closed, fired and removed, both donuts
were full-thickness, circumferential and completely intact. It was sent for
pathology for routine processing.
The proximal bowel was clamped off, the pelvis was filled with fluid. I
performed flexible sigmoidoscopy. There was no evidence of leak from the
anastomosis. The scope was now removed. The anastomosis appeared to be at
approximately 10 cm. There was no bleeding. Dr. Sherman then rescrubbed
into the case. A fascial suture made of 0 Vicryl was placed in the right
lower quadrant 10 mm port using a laparoscopic suture passer. A 19-French
drain was placed in the pelvis adjacent to the anastomosis and brought out
through this right lower quadrant wound. In addition, a 19-French JP was
placed in the left upper quadrant adjacent to the spleen. Since this, the
patient will be having anticoagulation to ensure no bleeding from the
splenic capsular tear and to ensure no pancreatitis as well. Both drains
were secured to the skin using Vicryl suture.
The abdomen was now desufflated. All ports and the wound protector were
removed. The fascia at the umbilical port site was closed with a
figure-of-eight 0 Vicryl suture. The fascia of the left lower quadrant
colostomy site was closed with 0 Vicryl running from both ends in a vertical
fashion and tied in the middle. All wounds were carefully cleaned and
anesthetized with 0.5 percent Marcaine solution. A pursestring suture was
placed in the skin of the colostomy to cinch it down and the central portion
was packed with saline-soaked gauze and covered with 4 x 4s. The umbilical
wound was covered with benzoin and Steri-Strips. Drain sponges were placed
around the 2 drains. An NG tube had been placed at the beginning of this
procedure. The patient was now awakened, extubated, and taken to the
recovery in stable condition having tolerated the procedure well.
Codes provider used: 44207,44227,44213,44180,45330
I coded as the following: (Please correct/educate me if I am wrong)
44207
44227,59,22
44213
45330
A time-out was performed. An incision was made around the colostomy.
Dissection continued down to the fascia. The fascia was circumferentially
mobilized until the significant portion of the left colon could be mobilized
through the wound. The colostomy remnant was resected. A pursestring suture
was placed around the cut end of colon, the anvil 29 EEA stapler was placed
in anticipation of an end-end anastomosis. There was occasional
diverticulosis, that was seen, which had not been seen on the colonoscopy.
The bowel was placed back into the abdomen and a Gelpoint wound protector
was placed. The top of the Gelpoint was also inserted. Pneumoperitoneum was
easily achieved. There were significant adhesions of omentum to the anterior
abdominal wall. A 5 mm port was placed in the left lower quadrant. These
adhesions were taken down using the Harmonic scalpel.
A 10 mm port was placed in the right lower quadrant, a 5 mm port was placed
in the right upper quadrant. The left colon could easily be seen. It was
retracted medially. The white line of Toldt was incised. The entire left
colon and splenic flexure were carefully mobilized. There is a small
capsular tear in the spleen that was easily controlled with fibrillar.
Dissection was now continued in a retroperitoneal fashion up under the
inferior mesenteric artery. This was circumferentially cleaned, divided with
an Echelon load with a white load. In addition, the IMV was also identified
and circumferentially clean and also divided with an Echelon load with a
white load. The vessels had to be taken in order to ensure adequate length
for reach for the anastomosis of the left colon.
With this accomplished, attention was now paid to the pelvis. The Hartmann
stump could easily be seen. The small bowel was lifted out of the pelvis.
The presacral space was entered. Dissection was continued to rest for short
distance until soft healthy, pliable area of rectum was identified just
above the peritoneal reflection. The mesorectum in this region was divided
with Harmonic scalpel. The rectum was divided with an Echelon load with a
gold load. The Hartmanns pouch remnant was then brought out through the
left lower quadrant ostomy site through the wound protector and sent to
pathology along with the colostomy remnant to Pathology for routine
processing.
A 29 EEA stapler was now inserted into the rectum until the end of the
stapler was flushed with the end of staple line. The trocars advanced. The
anvil of the proximal bowel was engaged onto the trocar. After ensuring
correct orientation, the stapler was closed, fired and removed, both donuts
were full-thickness, circumferential and completely intact. It was sent for
pathology for routine processing.
The proximal bowel was clamped off, the pelvis was filled with fluid. I
performed flexible sigmoidoscopy. There was no evidence of leak from the
anastomosis. The scope was now removed. The anastomosis appeared to be at
approximately 10 cm. There was no bleeding. Dr. Sherman then rescrubbed
into the case. A fascial suture made of 0 Vicryl was placed in the right
lower quadrant 10 mm port using a laparoscopic suture passer. A 19-French
drain was placed in the pelvis adjacent to the anastomosis and brought out
through this right lower quadrant wound. In addition, a 19-French JP was
placed in the left upper quadrant adjacent to the spleen. Since this, the
patient will be having anticoagulation to ensure no bleeding from the
splenic capsular tear and to ensure no pancreatitis as well. Both drains
were secured to the skin using Vicryl suture.
The abdomen was now desufflated. All ports and the wound protector were
removed. The fascia at the umbilical port site was closed with a
figure-of-eight 0 Vicryl suture. The fascia of the left lower quadrant
colostomy site was closed with 0 Vicryl running from both ends in a vertical
fashion and tied in the middle. All wounds were carefully cleaned and
anesthetized with 0.5 percent Marcaine solution. A pursestring suture was
placed in the skin of the colostomy to cinch it down and the central portion
was packed with saline-soaked gauze and covered with 4 x 4s. The umbilical
wound was covered with benzoin and Steri-Strips. Drain sponges were placed
around the 2 drains. An NG tube had been placed at the beginning of this
procedure. The patient was now awakened, extubated, and taken to the
recovery in stable condition having tolerated the procedure well.
Codes provider used: 44207,44227,44213,44180,45330
I coded as the following: (Please correct/educate me if I am wrong)
44207
44227,59,22
44213
45330