General Surgery Coding Alert

Question: How should we code the following case for an open gastrojejunostomy with vagotomy, pyloroplasty, and bleeding duodenal ulcer repair?
The op note follows:

Identified the pylorus and followed distally, noting approximately 2 cm area of necrosis with perforation of the anterior superior duodenal wall just distal to the hepatoduodenal ligament where the bile duct and the duodenum meet. Performed a Kocher maneuver, and on manipulation, the necrotic area fell away. Opened the duodenum longitudinally through the pylorus and debrided the necrotic portion of the duodenal wall, noting a bleeding vessel at the base of the ulcer, which was oversewn with silk sutures. I performed a Heineke-Mikulicz pyloroplasty. I then opened the hiatus and removed a segment from both the anterior and posterior vagus nerves and stripped the nerves from the esophagus. I then opened the transverse mesocolon and brought up the small bowel and performed a gastrojejunostomy with a stapling devise. I then brought 24 gastrostomy tube through the abdominal wall, opened the stomach through a purse-string suture and placed the tube in the stomach before tying the silk. I mobilized a segment of the omentum and placed this over the repair of the duodenum.

Ohio Subscriber

Answer: The best coding to describe this case would be 43825 (Gastrojejunostomy; with vagotomy, any type) plus 43800 (Pyloroplasty) for the pyloroplasty.

Don't double dip: You shouldn't report 43640 (Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective) for the pyloroplasty because 43825 already accounts for the vagotomy.

The note doesn't document a separate enterorrhaphy, as the repair appears from the op note to be part of the pyloroplasty. The over-sewing of the blood vessel also appears to bundle into the pyloroplasty service.

That said, if the surgeon doesn't believe that these two codes adequately describe the work involved in this case, she could consider a modifier 22 (Increased procedural services) on the pyloroplasty.

Caveat: The surgeon would need to add documentation to justify modifier 22, describing the extended time and effort involved in the procedure.