colostomy reversal and stoma hernia repair


Adel, IA
Best answers
Hi! This OP note is throwing me for a loop. I think I have it narrowed down to three codes since a lot of them are included in each other but need help to see if I'm on the right track or way off. Any advice would be appreciated! It starts out as laparoscop and converts to open procedure so I know I need some modifiers somewhere too- maybe just 22?

Op Procedure: 1. reversal of Hartmans type colostomy 2. diverting loop ileostomy creation 3. extensive adhesiolysis requiring three times the normal operating time at 6hrs 4. stomal hernia repair

Patient was brought to the operating suite where his identity and procedure were confirmed. He was placed on the table in the dorsal lithotomy position. General anesthesia was induced. The left lower quadrant colostomy was oversewn with 3-0 chromic. The abdomen, perineum and rectum were prepped and draped sterily. A 5mm right lower quadrant optical trocar was inserted. Pneumoperitoneum was created with carbon dioxide insufflation. Upon entry into the abdomen extensive adhesions were present between multiple small bowel loops and the anterior abdominal wall as well as obscuring the pelvis. An addition 5mm right lower quadrant port was inserted as well as epigastric 5mm port and using careful lenghty dissection with counter traction and sharp dissection with laparascopic scissors enterolysis was completed freeing the small bowel from the abdominal wall to allow visualization of the pelvis.

Multiple small bowel loops obscured the view of the rectal stump and these were carefully dissected up out of the pelvis allowing visualization of the rectal stump which was marked on either end of the staple line with Prolene tags.

Next the colostomy site was approached. Small bowel and mesentery was incarcerated in a peristomal hernia and this was all carefully reduced with again lengthy dissection using sharp dissection. Once all of this was reduced the unresected portion of colon in the pelvis was examined again and was felt to be too lengthy to allow maneuvering of the EEA stapler up through the lower end. At this point, it was elected to convert to an open procedure. A lower midline laparotomy was created and extended down through the peritoneum. An elliptical incision was made around the colostomy. Subcutaneous fat was divided down to the wall of the descending colon and this was dissected down to the fascial level and freed from adhesions and attachements. The distal few cms of the descending colon was sized with an EEA sizer at 29mm. The 29mm EEA sizer was passed easily into the colon and the anvil from the 29mm. EEA stapler was inserted and secured with 2-0 Prolene purse string suture. The EEA stapler was then inserted through the rectum and repeated careful attempts to maneuver the stapler up through the somewhat lengthier portion of the rectum and distal sigmoid colon were unsuccessful. There was insufficient length from the descending colon for a side to side anastomosis and it was noted at this point that the serosa had separated overlying the ridge of teh anvil. It was felt at this point that the only viable option was hand sewn anastomosis given the tenuous nature of the colon in this area. The purse string was cut and the anvil was removed. A 3-0 Vicryl stitch in the mesentery of the descending colon and the rectal stump was used to approximate the ends and a back row of interrupted 3-0 silk sutures. The rectum was insufflated with air with irrigation fluid in the pelvis to leak test the anastomosis and this was satisfactory without leakage. Because of the extended operating time and the advanced age of the patient as well as the difficulty creating the anastomosis it was elected to create a diverting ileostomy to protect the anastomosis during healing. A sutiable portion of the distal ileum was selected and delivered through an incision in the right lower quadrant which was extended through the fascia and rectus muscle wide enough to admit two fingers. The abdomen was thoroughly irrigated. All lap instruments were accounted for and fascia was sutured. The stomal hernia defect and stoma site were then closed repairing the hernia in a primary fashion with interrupted 0 Vicryl figure of eight sutures. A Penrose drain was places and teh skon was closed with staples. The midline was closed with staples. The ileostomy was then matured over a 24 French chest tube bar and ostomy appliance was placed. Patient tolerated the procedure well...

I came up with 44626 and 44310 with 22 modifier... I figured the adhesions are included and so is the stomal hernia repair if its billed with 44626. It sounds like a whole bunch of stuff going on and I feel like I'm missing some stuff? Any suggestions?
No, you aren't missing anything. You do need some resection in order to use the 44626, but there almost certainly was some, they just don't always make it real clear in the op note. Presumably you've got a path report for it. I would put the 22 on the 44626. I thought you might need a 59, even tho you shouldn't, but I checked my NCCI CD real quick & this particular combo isn't on there. (I think they've got the opposite combo in there, AND the narratives, as being "impossible" !?! - but not this one thank heavens!)
Thank you for your help! I am not good at understanding colostomies nor hernia's for that matter. I need a class. One more question for you if you can help- I know I have to send in the OP Note for the 22 modifier but here's what I have for diagnosis:

History of perforated diverticulitis requiring Harman's procedure- extensive intraabdominal adhesions- peristomal hernia-

So do I use 569.69- peristomal hernia, 568.0- abdominal adhesions (which says post-op- so I'm assuming this is ok from his previous history of surgeries??- and then V64.41- for lap to open procedure?