surgerycoder
Contributor
Can anyone assist me with coding on this one? physician wants to bill as a resection of the peritoneal tumor, a resection of the abdominal wall tumor, partial cystectomy and implantation of mesh. I’ve looked at this several times and not feeling that both codes for the removal of peritoneal tumor and abdominal wall tumor should be used since same tumor, but unsure of which way to go with the coding.
Preoperative diagnosis: History of familial adenomatous polyposis, colon cancer with enlarging, symptomatic abdominal wall desmoid tumor.
Postoperative diagnosis: Same, including involvement of peritoneum and dome of bladder.
Procedure: 1. Laparotomy with resection of peritoneal tumor, greater than 10 cm. 2. Resection of abdominal wall tumor including muscle and fascia, greater than 5 cm. 3. Partial cystectomy. 4. Reconstruction of abdominal wall with implantation of mesh.
Findings: Massive tumor arising and involving left abdominal wall rectus and oblique muscles, full-thickness including previous mesh and extending into peritoneum. Involvement of the dome of the bladder. No direct invasion into bowel.
Specimens: As above.
Implants: Prosthetic mesh.
Complications: None..
Description of procedure: Patient was brought to the operating room and identified and placed supine on the operating room table. Underwent induction of general endotracheal anesthesia at which point Foley catheter was placed. Patient's abdomen was prepped and draped standard surgical fashion. Midline incision created with 10 blade scalpel and the site of the previous scar. Electrocautery used to dissect through subcutaneous tissues down towards the level of the fascia. Because of the extensive tumor in the left abdomen extending beyond the midline towards the right rectus, we dissected through the medial portion of the rectus muscle to the level of the previously placed mesh. The mesh was then incised and we gain access to the peritoneal cavity. We then dissected superiorly and inferiorly dividing the mesh and fascia gaining further exposure of the peritoneum. There were some adhesions between the mesh and the bowel which were taken down sharply no evidence of any direct invasion into the bowel. Superiorly we then began to divide across the left rectus and oblique fascia and muscles with cautery beginning to mobilize the tumor more medially. The tumor did extend nearly to the origin of the oblique muscles. We then dissected down parallel to the tumor further dividing the lateral attachments from the muscle. Medially the tumor involved the peritoneum and the dome of the bladder. We dissected extraperitoneal with cautery and use an endovascular stapler device to staple across the very top of the bladder where the tumor was directly attached. We then divided the attachments right at the pubic symphysis and dissected laterally parallel to the inguinal ligament dividing these attachments with cautery and resecting the large mass. We then assessed for hemostasis. Next a large mesh was introduced and using #1 Ethibond sutures we secured initially the mesh laterally. Next the mesh was cut and then also secured to our right rectus and fascia layers completing the reconstruction. 2, 19 French drains were introduced through stab incisions and placed above the fascia and secured to the skin with 2-0 nylon suture. Subcutaneous layers were then approximated over the mesh with 2-0 Vicryl suture. Skin and soft tissues were irrigated and closed with a running staple line. Patient was then extubated transferred to recovery stable condition.
Path came back as ...
SOFT TISSUE, ABDOMINAL WALL, PERITONEAL MASS, RESECTION:
- FIBROMATOSIS (DESMOID TUMOR), NARROWLY EXCISED.
Preoperative diagnosis: History of familial adenomatous polyposis, colon cancer with enlarging, symptomatic abdominal wall desmoid tumor.
Postoperative diagnosis: Same, including involvement of peritoneum and dome of bladder.
Procedure: 1. Laparotomy with resection of peritoneal tumor, greater than 10 cm. 2. Resection of abdominal wall tumor including muscle and fascia, greater than 5 cm. 3. Partial cystectomy. 4. Reconstruction of abdominal wall with implantation of mesh.
Findings: Massive tumor arising and involving left abdominal wall rectus and oblique muscles, full-thickness including previous mesh and extending into peritoneum. Involvement of the dome of the bladder. No direct invasion into bowel.
Specimens: As above.
Implants: Prosthetic mesh.
Complications: None..
Description of procedure: Patient was brought to the operating room and identified and placed supine on the operating room table. Underwent induction of general endotracheal anesthesia at which point Foley catheter was placed. Patient's abdomen was prepped and draped standard surgical fashion. Midline incision created with 10 blade scalpel and the site of the previous scar. Electrocautery used to dissect through subcutaneous tissues down towards the level of the fascia. Because of the extensive tumor in the left abdomen extending beyond the midline towards the right rectus, we dissected through the medial portion of the rectus muscle to the level of the previously placed mesh. The mesh was then incised and we gain access to the peritoneal cavity. We then dissected superiorly and inferiorly dividing the mesh and fascia gaining further exposure of the peritoneum. There were some adhesions between the mesh and the bowel which were taken down sharply no evidence of any direct invasion into the bowel. Superiorly we then began to divide across the left rectus and oblique fascia and muscles with cautery beginning to mobilize the tumor more medially. The tumor did extend nearly to the origin of the oblique muscles. We then dissected down parallel to the tumor further dividing the lateral attachments from the muscle. Medially the tumor involved the peritoneum and the dome of the bladder. We dissected extraperitoneal with cautery and use an endovascular stapler device to staple across the very top of the bladder where the tumor was directly attached. We then divided the attachments right at the pubic symphysis and dissected laterally parallel to the inguinal ligament dividing these attachments with cautery and resecting the large mass. We then assessed for hemostasis. Next a large mesh was introduced and using #1 Ethibond sutures we secured initially the mesh laterally. Next the mesh was cut and then also secured to our right rectus and fascia layers completing the reconstruction. 2, 19 French drains were introduced through stab incisions and placed above the fascia and secured to the skin with 2-0 nylon suture. Subcutaneous layers were then approximated over the mesh with 2-0 Vicryl suture. Skin and soft tissues were irrigated and closed with a running staple line. Patient was then extubated transferred to recovery stable condition.
Path came back as ...
SOFT TISSUE, ABDOMINAL WALL, PERITONEAL MASS, RESECTION:
- FIBROMATOSIS (DESMOID TUMOR), NARROWLY EXCISED.