colectomy without colostomy or anastamosis

rykin7609

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Local Chapter Officer
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Alvin, TX
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I have surgeon who did an open procedure on a patient who had two perforations in the colon, one in the descending and the other in the simoid. Surgeon divided the colon just distal to the sigmoid and proximal to the descending but left the patient open with a ABThera wound vac. No Anastamosis, no colostomy.

I do not think I can bill for the 4414- series because non of those procedures were completed in any of the ways indicated. The closest one obviously is the 44146 or 44143. I do not want to bill with the 53 modifier if I can help it, I feel the doctor did so much more work clearing out the purulent fluid and stool. And a 49000 doesn't seem right either. The only other thing is the unlisted 45399? Or am I missing something and there is a code specifically for this procedure?

notes:

The patient was brought to the operating room and placed on the table in the
supine position. She had been intubated in the emergency room. Anesthesia was
induced and an arterial line was attempted to be placed by anesthesia. The
abdomen was prepped and draped in sterile fashion. A midline incision was then
made from just above the umbilicus to midway down, between the umbilicus and the
pubic tubercle. Dissection was carried down to the fascia with electrocautery.
This was opened in a controlled manner. There was return of dark fluid with
evidence of purulence and stool. This was cultured. We then extended the
peritoneal incision with electrocautery. There was a large redundant sigmoid
colon. There was a lot of fluid that was aspirated out. We then found multiple
stool balls down in the pelvis, again from approximately marble-sized up to
racquet-ball-sized. We were able to identify a perforation in that area. The
colon was then examined, extending up the descending colon were we found an area
of chronic perforation with a golf-ball-sized stool ball sitting within the
mesentery, no longer within the colon. This was removed. The colon was divided
just proximal to this perforation and just distal to the other perforation. We
then controlled the mesentery with the LigaSure device and specimen was passed
off the table. The remainder of the colon appeared to be intact, but there were
multiple stool balls within the colon the remainder of the length. The abdomen
was then irrigated with 2 L of saline. We then changed gloves and irrigated
with a liter of Betadine solution followed by 5 L more of saline. This was all
suctioned out and appeared clear. The small bowel was examined. There was no
evidence of injury or perforation of the small bowel. The orogastric tube was
palpated and found to be in good position within the stomach. We then placed an
ABThera wound VAC for temporary closure. The patient was taken to the ICU in
serious condition. We will plan to return to the operating room within the next
few days for washout and hopefully definitive closure of the abdomen, either
with colostomy or potentially anastomosis, although I think this is unlikely.
 

nlbarnes

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Escondido, CA
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Colectomy without colostomy or anastomosis

Hi - I was just sharing this exact scenario to a new surgeon today. I've had several cases in the past where I did this. In the seven years that I've been doing surgical coding, the claims were paid (not that that EVER means that it's indicative of a correctly coded claim) but a clinician from the payer(s) had to review the op report and it checked out. I do believe that I understand the proper usage of 52, but if I'm mistaken, someone please explain.

I didn't check the CPT code range you mentioned, but I will tell you that you can bill the intended codes with the modifier 52:

Definition of modifier 52:
Reduced Service reports a partially reduced or eliminated service or procedure.

Appropriate Usage
Procedures for which services performed are significantly less than usually required may be billed with the "52" modifier.
Report the service provided with modifier 52 and the appropriate reduced original charge.
Services modified at the physician's discretion to be less than the usual procedure.
When the documentation describing the service fully supports that the service furnished was less than usually required.
 
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