Hi! I have been given some surgery charts to code and I have no idea where to start. Is there anyone out there who is willing to help or teach? Here's an example of one I have worked on and what I came up with but not sure if it is correct at all.
Admit date: 12/13/2010
Preop DX: acute surgical abdomen w/complete small bowel obstruction.
Post-op DX: 1.Small bowel obstruction secondary to adhesive band with necrosis of the proximal ileum and distal jejunum requiring resection. 2. Palpable near obstructing mass in the cecum at the ileocecal valve.
Procedures:
1. Exploratory laparotomy and lysis of adhesions for relief of abstruction.
2. Enterectomy single resection and anastomosis.
3. Partial colectomy with ileostomy and mucous fistula formation.
Description of Procedure:
Upon entering the abdomen a large amount of darkly colored bloody fluid was evacuated from the peritoneum. Grossly distended necrotic small bowel was evident throughout the left side of the abdomen and a large number of adhesions and fibrinopurulent debris were present adhering multiple loops of small bowel together. Most of these were loosely broken up, the remainder were chronic adhesions and a tight adhesive band was found at the base of the mesentery causing necrosis of approximately 1/2 of the proximal ileum and the majority of the distal jejunum. Once the adhesive band causing the obstruction was lysed free and the small bowel up out of the pelvis viable portion of the small bowel proximal and distal to the necrotic area was divided with GIA stapler and the mesentery was divided with 2-0 silk ties. The specimen was handed off the table. The remainder of the abdomen was explored. The foul peritoneal fluid was evacuated and irrigated. Palpation of the colon revealed a firm near obstructing mass puckering the peritoneum in around the ileocecal valve and this was felt to be an impending obstruction as well unfortunately. The white line was taken down and the right colon was mobilized medially. The ureter was visualized. The colon was divided at the mid-ascending colon with the GIA stapler, the distal ileum was divided with the GIA and the mesentery was divided with vascular loads of the GIA. The specimen was handed off the table. Because the location of the necrotic portion although I would have preferred not to create an anastomosis given period of hypotension experienced during the operation I felt that the most proximal divsior of the jejunum if brought up as an ostomy would leave too little small bowel to be compatible with survival therefore a sisde to side functional end to end anastomosis was created at the small bowell division site with several firings of an ENDO GIA stapler. The anastomosis was palpably patent and the stable lines were hemostatic. I then created an ileostomy site in the right lower quadrant and brought up the distal ileum as wel as the corner of the colonic staple line to create a mucous fistula. The abdomen was ince again irrigated, hemostasis was confirmed. Counts were correct. THe fascia was closed in the midline with running 0-vicryl. The skin was loosely approximated with widely spaced staples and gauze was packed between the staples. The ileostomy and mucous fistula were then matured with interrupted 3-0 Vicryl sutures. An ostomy appliance was placed. Mucous appeared pink and viable. The patient was transferred to the recovery area in the critical condition on Neo drip.
I came up with CPT 44204 originally but I think I only need to use 44144 and 49000...
Thanks for any help provided!!!!
Admit date: 12/13/2010
Preop DX: acute surgical abdomen w/complete small bowel obstruction.
Post-op DX: 1.Small bowel obstruction secondary to adhesive band with necrosis of the proximal ileum and distal jejunum requiring resection. 2. Palpable near obstructing mass in the cecum at the ileocecal valve.
Procedures:
1. Exploratory laparotomy and lysis of adhesions for relief of abstruction.
2. Enterectomy single resection and anastomosis.
3. Partial colectomy with ileostomy and mucous fistula formation.
Description of Procedure:
Upon entering the abdomen a large amount of darkly colored bloody fluid was evacuated from the peritoneum. Grossly distended necrotic small bowel was evident throughout the left side of the abdomen and a large number of adhesions and fibrinopurulent debris were present adhering multiple loops of small bowel together. Most of these were loosely broken up, the remainder were chronic adhesions and a tight adhesive band was found at the base of the mesentery causing necrosis of approximately 1/2 of the proximal ileum and the majority of the distal jejunum. Once the adhesive band causing the obstruction was lysed free and the small bowel up out of the pelvis viable portion of the small bowel proximal and distal to the necrotic area was divided with GIA stapler and the mesentery was divided with 2-0 silk ties. The specimen was handed off the table. The remainder of the abdomen was explored. The foul peritoneal fluid was evacuated and irrigated. Palpation of the colon revealed a firm near obstructing mass puckering the peritoneum in around the ileocecal valve and this was felt to be an impending obstruction as well unfortunately. The white line was taken down and the right colon was mobilized medially. The ureter was visualized. The colon was divided at the mid-ascending colon with the GIA stapler, the distal ileum was divided with the GIA and the mesentery was divided with vascular loads of the GIA. The specimen was handed off the table. Because the location of the necrotic portion although I would have preferred not to create an anastomosis given period of hypotension experienced during the operation I felt that the most proximal divsior of the jejunum if brought up as an ostomy would leave too little small bowel to be compatible with survival therefore a sisde to side functional end to end anastomosis was created at the small bowell division site with several firings of an ENDO GIA stapler. The anastomosis was palpably patent and the stable lines were hemostatic. I then created an ileostomy site in the right lower quadrant and brought up the distal ileum as wel as the corner of the colonic staple line to create a mucous fistula. The abdomen was ince again irrigated, hemostasis was confirmed. Counts were correct. THe fascia was closed in the midline with running 0-vicryl. The skin was loosely approximated with widely spaced staples and gauze was packed between the staples. The ileostomy and mucous fistula were then matured with interrupted 3-0 Vicryl sutures. An ostomy appliance was placed. Mucous appeared pink and viable. The patient was transferred to the recovery area in the critical condition on Neo drip.
I came up with CPT 44204 originally but I think I only need to use 44144 and 49000...
Thanks for any help provided!!!!
Last edited:
I think I am going to use the 44144 and 44120.