crhunt78
Guru
I have an op report that I am having a difficult time dissecting. I wondered if anyone would be able to give me some direction. I am looking at coding as:
44145
44139
44140/59 vs. 44160/59
44310
Will you please let me know what you think? the documentation is not very clear when it comes to the terminal ileum so I can't decide which code to go with.
OPERATIVE PROCEDURE: The patient was brought to the operating. After
being prepped and draped in a sterile fashion, a midline incision was
made. Several liters of ascites were aspirated. The omentum was caked
with tumor, and this was removed from the transverse colon. It was
also stuck down into the pelvis. There were multiple loops of small
bowel adherent to the omentum at this point, and they were caked with
tumor. Therefore, decision was made at this point that she would have
to proceed with a right hemicolectomy including the small bowel. There
was also a large amount of tumor occluding the right colon. The left
colon was mobilized. The left ureter was identified. The uterus was
identified as well. A plane was made between the rectum and the
Uterus/vagina, and Dr. _____ will dictate her portion of the operation to
include a hysterectomy and a debulking. The inferior mesenteric artery
and vein were taken with clamps and ties. The mid descending colon was
transected with a stapler. The rectum was mobilized all the way down
below the peritoneal reflection to a point where there was no more
tumor. This was then transected, and that specimen was removed. After
clearing the abdomen of all other abdominal contents, the right colon
was identified and was mobilized. Multiple small tumors were removed
as well from this area, after taking the mesentery with the LigaSure
and the small bowel just proximal to the masses. A
side-to-side, functional end-to-end anastomosis was performed, and a
TA-60 was used to come across enterotomies, and the small bowel with
right colon was removed. The splenic flexure was then taken down using
electrocautery, taking down the splenic flexure completely, mobilizing
the colon all the way to the level of the mid transverse colon. A
pursestring suture was placed on the cut end of the colon, and an
end-to-end anastomosis was performed using a 29 mm stapler.
Insufflation revealed no evidence of leaking. Appropriate loop of
ileum was identified and was brought up through an opening made in the
right side of the abdomen. A valve was placed and sutured in place.
The area was irrigated thoroughly. Hemostasis was maintained. The
fascia was closed with #1 running PDS suture. The skin was closed with
staples. Sterile dressing was applied. Ileostomy was then matured
with 3-0 Vicryl sutures, and an ileostomy bag was placed.
Thanks for your help!!
44145
44139
44140/59 vs. 44160/59
44310
Will you please let me know what you think? the documentation is not very clear when it comes to the terminal ileum so I can't decide which code to go with.
OPERATIVE PROCEDURE: The patient was brought to the operating. After
being prepped and draped in a sterile fashion, a midline incision was
made. Several liters of ascites were aspirated. The omentum was caked
with tumor, and this was removed from the transverse colon. It was
also stuck down into the pelvis. There were multiple loops of small
bowel adherent to the omentum at this point, and they were caked with
tumor. Therefore, decision was made at this point that she would have
to proceed with a right hemicolectomy including the small bowel. There
was also a large amount of tumor occluding the right colon. The left
colon was mobilized. The left ureter was identified. The uterus was
identified as well. A plane was made between the rectum and the
Uterus/vagina, and Dr. _____ will dictate her portion of the operation to
include a hysterectomy and a debulking. The inferior mesenteric artery
and vein were taken with clamps and ties. The mid descending colon was
transected with a stapler. The rectum was mobilized all the way down
below the peritoneal reflection to a point where there was no more
tumor. This was then transected, and that specimen was removed. After
clearing the abdomen of all other abdominal contents, the right colon
was identified and was mobilized. Multiple small tumors were removed
as well from this area, after taking the mesentery with the LigaSure
and the small bowel just proximal to the masses. A
side-to-side, functional end-to-end anastomosis was performed, and a
TA-60 was used to come across enterotomies, and the small bowel with
right colon was removed. The splenic flexure was then taken down using
electrocautery, taking down the splenic flexure completely, mobilizing
the colon all the way to the level of the mid transverse colon. A
pursestring suture was placed on the cut end of the colon, and an
end-to-end anastomosis was performed using a 29 mm stapler.
Insufflation revealed no evidence of leaking. Appropriate loop of
ileum was identified and was brought up through an opening made in the
right side of the abdomen. A valve was placed and sutured in place.
The area was irrigated thoroughly. Hemostasis was maintained. The
fascia was closed with #1 running PDS suture. The skin was closed with
staples. Sterile dressing was applied. Ileostomy was then matured
with 3-0 Vicryl sutures, and an ileostomy bag was placed.
Thanks for your help!!