maine4me
Guru
Happy Monday everyone!! I am reviewing some denials for one of our surgeons (does his own coding), and I think the following should have been coded as a 45550, rather than 44140 amd 45540 as he coded it. Would someone please review and let me know if I am on the right track?
PREOPERATIVE DIAGNOSIS:
1. Profound rectal prolapse.
2. Marked redundancy of sigmoid colon.
POSTOPERATIVE DIAGNOSIS:
1. Profound rectal prolapse.
2. Marked redundancy of sigmoid colon.
3. Marked atrophy of pelvic floor musculature.
OPERATION:
1. Sigmoid colectomy with low anterior anastomosis (Baker type).
2. Pexy of descending colon to sacral promontory.
ANESTHESIA: General orotracheal
INDICATIONS FOR PROCEDURE: Patient is a 71-year-old white female who has chronic severe rectal prolapse, not amenable to perineal surgery.
OPERATIVE FINDINGS: The patient?s redundant sigmoid and transverse colon was readily apparent. The patient had virtually no muscle at the pelvic floor. Ureteral catheters were successfully inserted on both sides.
PROCEDURE AND FINDINGS: Patient was brought to the operating room and was placed on the operating table in supine position. A Time Out procedure was accomplished. After being correctly identified as to identity, proposed procedure, and operative site, general orotracheal anesthesia was administered . Cystoscopy and insertion of bilateral ureteral catheters was accomplished by Dr. G as per his operative note.
The abdomen and perineum were then prepped and draped in usual sterile fashion. A midline incision was then made and carried down through subcutaneous fat and through the anterior rectus muscle fascia. Hemostasis achieved with electrocautery. The peritoneum was entered. There were several adhesions which were taken down using the LigaSure Impact Device. The above findings were encountered. Marked redundancy of the sigmoid colon, as well as of the transverse colon, was encountered. There was marked atrophy of the pelvic floor muscles. At this point, the proximal sigmoid colon and left colon were mobilized by incising the white line of Toldt. The sigmoid colon was then gently freed from the pelvic brim. The proximal line of resection was then selected at the distal descending colon and the mesentery to this line of resection was divided using electrocautery, #3-0 and #0 Vicryl ties, and the LigaSure Device. The inferior mesenteric vessels were divided using double ligatures of #0 Vicryl. At this point, the proximal line of resection was divided. The proximal end of the colon was then gently dilated and the head of a 33-mm circular stapler was inserted into the proximal colonic lumen. The stapler head trocar was then brought out through the side wall of the colon, on the anti-mesenteric side of the descending colon. A purse-string suture was placed and tied around the shaft of the stapler head. The distal end of the proximal segment of colon was then closed with a transverse application of the TA-60 stapler. The distal sigmoid colon and mesentery were then elevated off the pelvic rim with care being taken not to injure either ureter. Dissection was then carried down into the pelvis. Once this dissection had progressed to the site of the distal line of resection (4 cm from the anal verge)), the colonic mesentery was divided using the LigaSure Device and #0 Vicryl ligatures. The distal line of resection was then transected using a Contour stapler. The specimen was removed. The proximal end of the colon would easily reach the distal segment, without any tension whatsoever. The 33-mm circular stapler was then inserted per rectum, in a retrograde fashion, until reaching the proximal, blind end of the distal colonic segment. The stapler was positioned properly and the trocar was brought through the stapled end of the distal segment. The head of the stapler was then attached to the stapler trocar, the bowel was properly aligned, and the stapler was approximated and fired. This resulted in a Baker style anastomosis. The stapler was removed from the anus and the anastomosis was tested using the air insufflation technique. No leaks were identified. The ?doughnuts? from the stapler were removed, found to be intact, and sent separately to Pathology. The pelvis was then irrigated with copious amounts of normal saline and irrigant was aspirated. The descending colon, above the anastomosis, was then sutured to the sacral promontory to pexy the colon and prevent recurrent rectal prolapses. Gowns, gloves, and instruments were changed. Additional drapes were applied to the operative field. At this point, there being no bleeding, the posterior rectus fascia and peritoneum were closed using a running #1 PDS suture. The anterior rectus fascia was then closed using a running #1 Prolene suture with the knots buried. Sub-cutaneous fat was closed with a running #2-0 Vicryl suture. The skin was closed using the skin staple gun. The patient, having tolerated the procedure well, was then awakened and taken to the Post Anesthesia care unit in stable condition. Sponge, needle counts correct x2, instrument count correct x1. Estimated blood loss minimal.
Thanks in advance for your help!!
PREOPERATIVE DIAGNOSIS:
1. Profound rectal prolapse.
2. Marked redundancy of sigmoid colon.
POSTOPERATIVE DIAGNOSIS:
1. Profound rectal prolapse.
2. Marked redundancy of sigmoid colon.
3. Marked atrophy of pelvic floor musculature.
OPERATION:
1. Sigmoid colectomy with low anterior anastomosis (Baker type).
2. Pexy of descending colon to sacral promontory.
ANESTHESIA: General orotracheal
INDICATIONS FOR PROCEDURE: Patient is a 71-year-old white female who has chronic severe rectal prolapse, not amenable to perineal surgery.
OPERATIVE FINDINGS: The patient?s redundant sigmoid and transverse colon was readily apparent. The patient had virtually no muscle at the pelvic floor. Ureteral catheters were successfully inserted on both sides.
PROCEDURE AND FINDINGS: Patient was brought to the operating room and was placed on the operating table in supine position. A Time Out procedure was accomplished. After being correctly identified as to identity, proposed procedure, and operative site, general orotracheal anesthesia was administered . Cystoscopy and insertion of bilateral ureteral catheters was accomplished by Dr. G as per his operative note.
The abdomen and perineum were then prepped and draped in usual sterile fashion. A midline incision was then made and carried down through subcutaneous fat and through the anterior rectus muscle fascia. Hemostasis achieved with electrocautery. The peritoneum was entered. There were several adhesions which were taken down using the LigaSure Impact Device. The above findings were encountered. Marked redundancy of the sigmoid colon, as well as of the transverse colon, was encountered. There was marked atrophy of the pelvic floor muscles. At this point, the proximal sigmoid colon and left colon were mobilized by incising the white line of Toldt. The sigmoid colon was then gently freed from the pelvic brim. The proximal line of resection was then selected at the distal descending colon and the mesentery to this line of resection was divided using electrocautery, #3-0 and #0 Vicryl ties, and the LigaSure Device. The inferior mesenteric vessels were divided using double ligatures of #0 Vicryl. At this point, the proximal line of resection was divided. The proximal end of the colon was then gently dilated and the head of a 33-mm circular stapler was inserted into the proximal colonic lumen. The stapler head trocar was then brought out through the side wall of the colon, on the anti-mesenteric side of the descending colon. A purse-string suture was placed and tied around the shaft of the stapler head. The distal end of the proximal segment of colon was then closed with a transverse application of the TA-60 stapler. The distal sigmoid colon and mesentery were then elevated off the pelvic rim with care being taken not to injure either ureter. Dissection was then carried down into the pelvis. Once this dissection had progressed to the site of the distal line of resection (4 cm from the anal verge)), the colonic mesentery was divided using the LigaSure Device and #0 Vicryl ligatures. The distal line of resection was then transected using a Contour stapler. The specimen was removed. The proximal end of the colon would easily reach the distal segment, without any tension whatsoever. The 33-mm circular stapler was then inserted per rectum, in a retrograde fashion, until reaching the proximal, blind end of the distal colonic segment. The stapler was positioned properly and the trocar was brought through the stapled end of the distal segment. The head of the stapler was then attached to the stapler trocar, the bowel was properly aligned, and the stapler was approximated and fired. This resulted in a Baker style anastomosis. The stapler was removed from the anus and the anastomosis was tested using the air insufflation technique. No leaks were identified. The ?doughnuts? from the stapler were removed, found to be intact, and sent separately to Pathology. The pelvis was then irrigated with copious amounts of normal saline and irrigant was aspirated. The descending colon, above the anastomosis, was then sutured to the sacral promontory to pexy the colon and prevent recurrent rectal prolapses. Gowns, gloves, and instruments were changed. Additional drapes were applied to the operative field. At this point, there being no bleeding, the posterior rectus fascia and peritoneum were closed using a running #1 PDS suture. The anterior rectus fascia was then closed using a running #1 Prolene suture with the knots buried. Sub-cutaneous fat was closed with a running #2-0 Vicryl suture. The skin was closed using the skin staple gun. The patient, having tolerated the procedure well, was then awakened and taken to the Post Anesthesia care unit in stable condition. Sponge, needle counts correct x2, instrument count correct x1. Estimated blood loss minimal.
Thanks in advance for your help!!