nlbarnes
Expert
I wanted to code this 44204-52 but the doctor wants to only bill the appy (doctor: as it was just a staple line across the cecum, higher than you usually do an appendectomy alone so trickier to do but not a formal bowel resection with anastomosis. It is a lot closer to an appendectomy than a right colectomy as far as the difficulty of doing the case and caring for the patient). Now I want to code just the appy but want to make sure it doesn't qualify as a partial cecectomy. I saw in old forums that people felt 44204-52 was appropriate but their cases could have been a bit different.
I was also considered 44970, often considered incidental as it's attached & resected with the cecum pending path (incidental small tubular adenoma of the appendix involving the cecum).
I'd appreciate feedback.
POSTOPERATIVE DIAGNOSIS:
Cecal polyp at the appendiceal orifice.
PROCEDURE:
Laparoscopic appendectomy with partial cecectomy.
INDICATION:
On colonoscopy has a 2 cm
polyp at the appendiceal orifice which cannot be removed
colonoscopically. It was a villous adenoma on biopsy. Presents
for resection of the polyp whether we can do this with a cecectomy or
whether she would require a full right colectomy.
DESCRIPTION OF PROCEDURE:
Looking at the cecum carefully, I could just see a small
spot of blue ink which was just distal to the ileocecal valve in the
center of the anterior wall of the cecum. I elevated the cecum
superiorly by holding the appendix and the terminal ileal fat pad, and
using the #5 Enseal, I gradually dissected off the mesentery, so that
both the appendiceal artery was divided with a #5 Enseal and then all
of the fatty mesentery around the cecum taken down and I took down the white
line of Toldt laterally as well, so that the cecum was fully cleaned off,
where it was distal to the ileocecal valve. I had no sense from the external
aspect of the polyp itself. I then placed an Endo-GIA 60 blue stapler across
the base of the cecum just inferior to the ileocecal valve to the best of my
ability maintaining the integrity of the ileocecal valve, but given where the
ink was located staying as close to it as I thought was possible. It took 2
fires of the stapler to excise the base of the cecum with the appendix with
it. I opened the specimen on the back table by trimming
off the edge of the staple line and everted the specimen and I could see that
there was in fact about a 2 cm soft villous appearing polyp with no hard by
palpation portions right at the orifice of the appendix, there was therefore
no gross evidence of cancer. I looked at the margin around the polyp and it
appeared clear grossly. I then placed a suture closing where I had opened
right along the staple line as that the staple line to the same site of the
polyp that small amount of tissue provides some additional margin as
well. As this patient only had a polyp and it appeared completely excised, I decided to
conclude the surgery at this point.
I was also considered 44970, often considered incidental as it's attached & resected with the cecum pending path (incidental small tubular adenoma of the appendix involving the cecum).
I'd appreciate feedback.
POSTOPERATIVE DIAGNOSIS:
Cecal polyp at the appendiceal orifice.
PROCEDURE:
Laparoscopic appendectomy with partial cecectomy.
INDICATION:
On colonoscopy has a 2 cm
polyp at the appendiceal orifice which cannot be removed
colonoscopically. It was a villous adenoma on biopsy. Presents
for resection of the polyp whether we can do this with a cecectomy or
whether she would require a full right colectomy.
DESCRIPTION OF PROCEDURE:
Looking at the cecum carefully, I could just see a small
spot of blue ink which was just distal to the ileocecal valve in the
center of the anterior wall of the cecum. I elevated the cecum
superiorly by holding the appendix and the terminal ileal fat pad, and
using the #5 Enseal, I gradually dissected off the mesentery, so that
both the appendiceal artery was divided with a #5 Enseal and then all
of the fatty mesentery around the cecum taken down and I took down the white
line of Toldt laterally as well, so that the cecum was fully cleaned off,
where it was distal to the ileocecal valve. I had no sense from the external
aspect of the polyp itself. I then placed an Endo-GIA 60 blue stapler across
the base of the cecum just inferior to the ileocecal valve to the best of my
ability maintaining the integrity of the ileocecal valve, but given where the
ink was located staying as close to it as I thought was possible. It took 2
fires of the stapler to excise the base of the cecum with the appendix with
it. I opened the specimen on the back table by trimming
off the edge of the staple line and everted the specimen and I could see that
there was in fact about a 2 cm soft villous appearing polyp with no hard by
palpation portions right at the orifice of the appendix, there was therefore
no gross evidence of cancer. I looked at the margin around the polyp and it
appeared clear grossly. I then placed a suture closing where I had opened
right along the staple line as that the staple line to the same site of the
polyp that small amount of tissue provides some additional margin as
well. As this patient only had a polyp and it appeared completely excised, I decided to
conclude the surgery at this point.
Last edited: