MALT Lymphoma Confined to Colon

This is a good example of why coders should always begin their diagnostic search in the Alphabetic Index to Diseases, Volume 2, of ICD-9-CM. If the coder skips that step and jumps right to the Neoplasm Table, the nature of the neoplasm is missed altogether.

Mucosa associated lymphoid tissue (MALT) is a form of lymphoma, and is classified differently from other intestinal neoplasia. From MALT in Volume 2 of ICD-9-CM, the reader is directed to 200.3 Marginal zone lymphoma. The fifth-digit here is tricky. Although most of these fifth digits are for lymph nodes by site, MALT represents lymphoid tissue, not nodes. The fifth digit 3, for intra-abdominal nodes, would not be appropriate. Instead, report fifth-digit 0, which includes solid organ sites.

Timing matters in this case. The patient, having recovered well and finished chemotherapy, would graduate from 200.30 Marginal zone lymphoma of unspecified site, extranodal and solid organ sites to V10.71 Personal history of lymphoma and reticulosarcoma. During active treatment, 200.30 would be reported.

Timing also factors into the reported procedures. It seems at least four encounters occur within this note, excluding chemotherapeutic sessions: (1) The initial preventive exam; (2) a colonoscopy with biopsy; (3) the colectomy; and (4) a final E/M visit when the patient had completed chemotherapy.

For the initial E/M service, the primary care physician would bill for the routine health exam using 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years with V70.0 Routine general medical examination at a health care facility. Based on ICD-9-CM coding guidelines section I.C.18.d.13, any diagnosis or condition discovered during the exam should also be reported (as discussed below).

The physician performing the scope and sampling has scant documentation, so 45380 Colonoscopy, flexible, proximal to splenic flexture; with biopsy, single or multiple is the best choice. Excision codes would be used if the excisions were documented.

If the pathology report was received before billing, the diagnosis accompanying the colonoscopy would be 569.89 Specified disorders of intestine; other (if we assume the mass was found in the intestine—the record indicates only “mass,” without a location). Other possible choices include 793.99 Other nonspecific abnormal findings on radiological and other examinations of body structure and 787.99 Symptoms involving digestive system; other.

If the path report had been received, the diagnoses would be 230.30 for the MALT and 211.4 Benign neoplasm of rectum and anal canal for the hyperplastic polyp.

The physician performing the colectomy would report 44140 Colectomy, partial; with anastomosis with 230.30. This assumes that the colectomy occurred at a different session from the colonoscopy. If the colonoscopy and colectomy occurred during the same session, only the colectomy would be reported because the National Correct Coding Initiative (CCI) bundles 45380 to 44140.

Not enough information is available to determine an E/M code for the final encounter.

A Big Mesh

This case involves a return to the operating room for the third time to correct a right flank bulge, using existing mesh and Mitek Quick Anchors to hold the mesh in place.
Accessing the site is made more difficult by the substantially altered surgical field. Can you code this?

Postoperative diagnosis: Right flank bulge/hernia.

Procedure: Repair of right flank bulge with existing mesh and Mitek interosseous ileal Quick Anchor securing device.

Indications for procedure: Patient is a 72-yr-old man who had a right nephrectomy some years ago through a right flank incision. This gave him a debilitating flank bulge. He has had three previous, failed attempts at repair, in which a fairly large sheet of Marlex® mesh was placed.

Findings: The old mesh was intact, but not well secured inferiorly or anteriorly. The previous mesh was retained. Five Mitek Quick Anchor devices were placed by down in the hip, with those sutures used to secure the mesh inferiorly.

Procedure: The patient was brought to the operating room … After he was prepped a very lengthy elliptical incision was made, taking out the old incision and getting down through the scar tissue into the fat. Dissecting through the fat, the surgeon came across some of the muscle and the fascia. This was obviously quite attenuated and the planes were difficult to discern because of the previous surgeries. The surgeon dissected down to the mesh, which showed no sign of infection, lifting out muscle as it was found. The mesh was not well supported anteriorly and medially, and the surgeon placed Prolene sutures through-and-through the muscle from a para right rectus position through five separate stab incisions in this skin, as though he were fixing a hernia with the laparoscopic technique.

The surgeon exposed a 1.5 cm area of the ilial wing, starting all the way from the anterior superior iliac spine, back as far posteriorly as could be identified, and running underneath the oblique muscles.

Several spaces were mapped out for attachment of the anchors and at each spot a small hole was created in the internal oblique muscle, as it attached using electrocautery, exposing the underlying bone, which was only approximately 1-2 mm deep to this layer. A small area of this bone was exposed, such that the step drill could be placed under direct visualization on to the bone and drilled in. A Mitek Quick Anchor was then placed, such that the wings of the anchor were parallel to the iliac crest. It was then pulled back to ensure that the anchor was firmly placed. This was accomplished in a total of five locations, extending from the level adjacent to the anterior superior iliac spine laterally to the posterior aspect of the iliac crest.

The attached #2 nonabsorbable suture was then used to pull the preexisting mesh, which appeared well incorporated into the soft tissues, down to the area of the iliac crest. This resulted in firm approximation of the mesh to the iliac crest and elimination of the distal aspect of the defect in the abdominal wall. All sutures appeared to be firmly anchored.

The muscle layers were confused, particularly anteriorly. Closure occurred in two layers. The whole case was very difficult and took over four hours, due to the substantially altered surgical field.

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