- Messages
- 5
- Location
- Nacogdoches, TX
I have recommendation from one set of coders to remove 43501 as it is a duodenal ulcer, not a gastric ulcer so it is considered part of the pyloroplasty, while other coders recommend removing the 43800 per the general CMS guidelines that the opening and closing of the stomach is inherent to the gastrostomy. I can find no articles or further guidelines to help me chose the most accurate coding for this case. Any help would be greatly appreciated. Here is the operative report:
After the patient was palpated for informed consent was obtained was taken to the operating room placed upon on the operating table and general tracheal anesthesia was induced. Nasogastric tube and Foley catheter were placed. The abdomen was prepped and draped in usual sterile fashion. Vertical midline incision was made from the xiphoid region supraumbilical region through the skin and subcutaneous tissue. The fascia was opened in the midline with electrocautery peritoneum was opened to the intra-abdominal cavity. Immediately identifiable was moderately distended small bowel filled with what appeared to be old blood. Patient was placed in reverse Trendelenburg position and I retracted the omentum inferiorly to expose the stomach. We then placed a Balfour retractor to expose the stomach and duodenum. The stomach was not significantly distended or discolored. Modified Kocher maneuver maneuver was performed to mobilize portion of the duodenum to the midline. I placed four 3-0 Vicryl stay sutures around the duodenal bulb and distal stomach. I then made a transverse duodenal gastrotomy with electrocautery. This across the pylorus. Once we entered the duodenum there was nonbloody bile being expressed. I could not visualize and palpate the clips placed by gastroenterology previously and there was no significant bleeding from these areas. There was 1 minor duodenal ulcer which was actively bleeding and this was oversewn/suture-ligated with interrupted 3-0 Vicryl suture. This involved a branch of the gastroduodenal artery as well. Further inspection of his root region revealed no active bleeding and a large amount of bilious secretion which was clear yellow and nonbloody. At this point a pyloroplasty was performed this was done by closing the duodenum counter direction at which was opened to the incision. This was done with full-thickness closure with a running 3-0 PDS suture and several interrupted 3-0 Vicryl Lembert sutures over the suture line. This also allowed for minimization of pyloric stenosis after closure. Next fibrin glue was applied over the suture line. Because of the mesenteric defect for mobilization of the C-loop of the duodenum I mobilized a portion of the omentum as an internal omental flap this was done with a LigaSure device and remained with a vascular pedicle attached to the transverse colon. I then used 3-0 Vicryl suture to suture the pedicled flap over the top of the suture line and to fill the defect of the mesentery under the stomach and duodenum for mobilization of the duodenum. Next a 19 French JP drain was placed with the working and around the omental flap and the suture line. The wound was irrigated NG tube confirmed proper position of the stomach the midline fascia was then closed with a running #1 looped double-stranded PDS suture and a interrupted #1 Vicryl internal retention sutures local anesthetic infiltrated the subcutaneous subfascial planes wound was irrigated and skin closed with staples and a sterile dressing was applied. The patient tolerated procedure well. There are no complications. The sponge needle and instrument count were correct at the end the case.
After the patient was palpated for informed consent was obtained was taken to the operating room placed upon on the operating table and general tracheal anesthesia was induced. Nasogastric tube and Foley catheter were placed. The abdomen was prepped and draped in usual sterile fashion. Vertical midline incision was made from the xiphoid region supraumbilical region through the skin and subcutaneous tissue. The fascia was opened in the midline with electrocautery peritoneum was opened to the intra-abdominal cavity. Immediately identifiable was moderately distended small bowel filled with what appeared to be old blood. Patient was placed in reverse Trendelenburg position and I retracted the omentum inferiorly to expose the stomach. We then placed a Balfour retractor to expose the stomach and duodenum. The stomach was not significantly distended or discolored. Modified Kocher maneuver maneuver was performed to mobilize portion of the duodenum to the midline. I placed four 3-0 Vicryl stay sutures around the duodenal bulb and distal stomach. I then made a transverse duodenal gastrotomy with electrocautery. This across the pylorus. Once we entered the duodenum there was nonbloody bile being expressed. I could not visualize and palpate the clips placed by gastroenterology previously and there was no significant bleeding from these areas. There was 1 minor duodenal ulcer which was actively bleeding and this was oversewn/suture-ligated with interrupted 3-0 Vicryl suture. This involved a branch of the gastroduodenal artery as well. Further inspection of his root region revealed no active bleeding and a large amount of bilious secretion which was clear yellow and nonbloody. At this point a pyloroplasty was performed this was done by closing the duodenum counter direction at which was opened to the incision. This was done with full-thickness closure with a running 3-0 PDS suture and several interrupted 3-0 Vicryl Lembert sutures over the suture line. This also allowed for minimization of pyloric stenosis after closure. Next fibrin glue was applied over the suture line. Because of the mesenteric defect for mobilization of the C-loop of the duodenum I mobilized a portion of the omentum as an internal omental flap this was done with a LigaSure device and remained with a vascular pedicle attached to the transverse colon. I then used 3-0 Vicryl suture to suture the pedicled flap over the top of the suture line and to fill the defect of the mesentery under the stomach and duodenum for mobilization of the duodenum. Next a 19 French JP drain was placed with the working and around the omental flap and the suture line. The wound was irrigated NG tube confirmed proper position of the stomach the midline fascia was then closed with a running #1 looped double-stranded PDS suture and a interrupted #1 Vicryl internal retention sutures local anesthetic infiltrated the subcutaneous subfascial planes wound was irrigated and skin closed with staples and a sterile dressing was applied. The patient tolerated procedure well. There are no complications. The sponge needle and instrument count were correct at the end the case.