Wiki repair of small intestine and anastomosis of small intestine to small intestine

[amandakay692]

Ok I am stumped and possibly over thinking all of this. So The surgeon started out doing a diagnostic laparoscopy which turned into a laparotomy and resulted in multiple procedures with all three being caused by dense adhesions but in different ways and I am unsure if I have chosen the right CPT codes and keep second guessing the ICD 10 CM codes:

44602 Repair of small intestine: As we entered the peritoneal cavity, some dark colored serosanguineous fluid was visualized. We were able to carefully eviscerate portions of the small bowel for inspection. We immediately were able to visualize a small perforation in the distal jejunum which appeared to be leaking some green stool. It appeared that this perforation was densely adhesed to some omentum and had not leaked a great deal of contamination into the peritoneal cavity until we exteriorized this piece of small bowel. However, the perforation did appear to be inflamed and thickened consistent with an existing perforation, and not something that had occurred during our manipulation of the small bowel.

44120 Anastomosis of small intestine to small intestine: As we continued to run the bowel distally, we found a dense adhesion across a segment of proximal ileum. The adhesion was lysed and we found that the underlying ileum appeared to be gray and necrotic. The small bowel was dilated proximal to this and collapsed distal to this. This had clearly been the site of the small bowel obstruction. Just proximal to the point of obstruction, there was approximately a 20 cm portion of small bowel that appeared hyperemic and necrotic in places. This area was well demarcated from the healthy bowel. The decision was made to resect this bowel completely and perform reanastomosis of the healthy ends of small bowel.

44950, +44955 Appendectomy: The small bowel is again carefully inspected from into intact and no further pathology was found. We found that the appendix had been involved in some of the dense adhesions in the pelvis which had initially cause the small bowel obstruction. Due to concern for an impending appendiceal inflammation, the decision was made to proceed with a stapled appendectomy

Findings: 1) small bowel perforation in mid jejunum densely adhesed to a piece of omentum (which may explain the lack of free air on previous radiographs), closed primarily 2) small bowel obstruction caused by a dense adhesion across the ileum. 3) hyperemic, partially necrotic segment of ileum, approximately 20 cm, resected and healthy ends small bowel reanastomosed 4) appendix visualized to be involved with adhesions in the pelvis and was removed

 

[cbutsko]

I think the first 2 are correct, and the appy should be the 44955. I'd bill it as 44120, 44602-59, 44955 all with the appropriate dx codes tied to each. Be sure to check the path report, especially for the appendix as you may find a more clear-cut dx for that. Also, don't forget to add the laparoscopic converted to open dx code, Z53.31.

I hope that helps a bit.

 

[amandakay692]

I think the first 2 are correct, and the appy should be the 44955. I'd bill it as 44120, 44602-59, 44955 all with the appropriate dx codes tied to each. Be sure to check the path report, especially for the appendix as you may find a more clear-cut dx for that. Also, don't forget to add the laparoscopic converted to open dx code, Z53.31.

I hope that helps a bit.

Thank you! Would the dx code Z53.31 need to be added to all of them?

 

[cbutsko]

Thank you! Would the dx code Z53.31 need to be added to all of them?

My apologies for the delay in answering. I was gone on vacation. Does the Op Report specify at what point the conversion to open was done? For example, if it was done BEFORE the surgeon did any of the three procedures then, yes, it would be attached to all three. My surgeons know to specify in detail when they do a conversion.

 

[amandakay692]

My apologies for the delay in answering. I was gone on vacation. Does the Op Report specify at what point the conversion to open was done? For example, if it was done BEFORE the surgeon did any of the three procedures then, yes, it would be attached to all three. My surgeons know to specify in detail when they do a conversion.

The patient was brought to the operating suite and placed in supine position on the operating table. General tracheal anesthesia was induced. A time-out was taken to verify the correct patient, correct procedure, and correct side and site of surgery. Preoperative antibiotics were given. The abdomen was prepped and draped in the usual sterile fashion. A Verses needle was placed at palmer's point, at the left costal margin at the midclavicular line, and the abdomen was insufflated 15 mm mercury carbon dioxide gas. The patient tolerated insufflation well. An 11 mm trocar and laparoscope were inserted into the left lateral abdomen using the Optiview technique. The laparoscope was fully inserted in the abdomen was inspected. There was a thin rind covering some large dilated loops of small bowel. There was some murky, dark colored fluid covering the small bowel and in the pericolic gutters and perihepatic gutter. Due to these findings, the decision was made to convert to open laparotomy to complete the case.

 

[cbutsko]

The patient was brought to the operating suite and placed in supine position on the operating table. General tracheal anesthesia was induced. A time-out was taken to verify the correct patient, correct procedure, and correct side and site of surgery. Preoperative antibiotics were given. The abdomen was prepped and draped in the usual sterile fashion. A Verses needle was placed at palmer's point, at the left costal margin at the midclavicular line, and the abdomen was insufflated 15 mm mercury carbon dioxide gas. The patient tolerated insufflation well. An 11 mm trocar and laparoscope were inserted into the left lateral abdomen using the Optiview technique. The laparoscope was fully inserted in the abdomen was inspected. There was a thin rind covering some large dilated loops of small bowel. There was some murky, dark colored fluid covering the small bowel and in the pericolic gutters and perihepatic gutter. Due to these findings, the decision was made to convert to open laparotomy to complete the case.

I would apply the lap converted to open dx to all of the procedure codes.