Help with OP note please

[lindacoder]

PROCEDURE:Exploratory laparotomy, extensive lysis of adhesions lasting greater than 2 hours, subtotal colectomy, component separation hernia repair and abdominoplasty.

A midline laparotomy incision was made using the patient's previous incision. This was deepended down through the fascia and his peritoneum was entered. At this point we performed extensive lysis of adhesions > 2 hours. Once the lysis of adhesions was complete we began moblizing his colon. His splenic flexure was taken down as well as his gastrocolic omentum. At this poing moving into the pelvis we identified the recurrent colon cancer. We then proceeded with an omentectomy. The colon was further mobilized until the previous ileocolic anastomosis was identified. The mesenteric _____________ was also mobilized and subsequently divided between Pean clamps. At this point we made a window in the mesentery of small bowel. Next, we continued mobilization of our distal rectum down into the pelvis, identifying the ureters. The omentum was taken down off the stomach using the Harmonic scapel. Next, the terminal ileum was divided with a 75-mm blue load GIA stapler. The enterotomy was made in the distal small bowel and the anvil through the EA stapler was introduced into the terminal ileum and a pursestring suture was fashioned around the anvil. At this point the remaining portions of the mesentery to the colon was sequentially divided and ligated between Pean clamps. The site distal to the tumor was chosen on the distal rectum. The rectum was divided using another 75-mm blue load GIA stapler. At this point the specimen was removed from the field.

Turning our attention to the rectum, the dilators were sequentially inserted into the rectal stump up to 29 mm. Next, the stapling device was inserted into the distal rectum and married with the anvil in the terminal ileum. The device was closed and fired revealing two donuts of tissue on the stapler. Next, the pelvis was filled with sterile saline and the rigid sigmoidoscope was entered into the distal rectum and insufflated. There were no buubles seen in the pelvis.

After changing gloves, we turned our attention to the abdomen. Hemostasis was achieved. The abdomen was re-explored. The mesentery was reapproximated using a running 4-0 PDS suture. Next, the abdominal wall wa closed in a component separation fashion due to the extent of the ventral incisional hernia the patient had. The fascial edges of each side were elevated with Kochers and the subcuaneous tissue as elevated up off the anterior rectus sheath. This was taken back to the medial border of the rectus abdominis muscle which was then incised allowing us access to both anterior and posterior fascial edges. The posterior fascia was then closed with a running 0 loop PDS suture. The previous scar from the abdominal wall was excised widely. the wound was explored for hemostasis. Next a wound VAC was placed into the abdominal wound and placed to suction.

Looking at 44150, 44139, 49560, 15830,15847 plus adding time for lysis of adhesions. Any help is appreciated!!!!

[smsmith]

Unless I missed it, I don't see an ileostomy being created in that note. Instead of a total colectomy code, you might look at one of the partial colectomy codes. You can't use the 44139 add on code with a total colectomy code, only the partial colectomy codes. For the 2 hours of lysis of adhesions, I would add -22 modifier to the colectomy coded and add at least 25 percent to the fee. One of my doctors brought me an article in the ACS Journal about coding component separation during ventral hernia repairs. That article recommends using 15734 for the component separation. I would love to know what other general surgery coders are doing for the component separation procedure.

Any other thoughts?

Susan Smith, CPC

[colorectal surgeon]

http://www.goremedical.com/resources...ssets/MCPC.pdf

found this on the internet.

[smsmith]

That is an excellent article! That is exactly what I have been stressing over. The fact that the reimbursement is so high for the 15734, it puts the 49560-49568 as a lesser valued codes, when the primary procedure was the ventral hernia, not the flap. I am going to refer this to the surgeons I code for and see what they want me to do on these component separation procedures.