Hello-
Can anyone tell me if creating a posterior rectus advancement flap is considered part of the component separation procedure? The report below was coded as 15734, 15734-59, 15734-59, 49565, 49568, 49560, 49568.
Humana has denied 15734 saying the procedure is not supported by the operative report. I believe 15734 was coded once to report the posterior rectus advancement flap, and then twice with mod -59 to report the left and right component separation.
OPERATIVE PROCEDURE:
The patient was placed on the operating table and after a successful induction
of anesthesia, the operative field was prepped and draped in the usual manner.
The scar was marked, as were the palpable edges of the hernia.
Incision was made on either edge of the scar and carried down through
subcutaneous tissue. The subcutaneous tissue was lifted off scar and fat
until the right left fascia was able to be identified, and this was identified
circumferentially. The scar itself was de-epithelialized. A right posterior
rectus sheath/cicatricial flap was developed, approximately 6 cm in width.
This was then advanced medially.
All adhesions were lysed to the abdominal wall. The posterior
sheath/cicatricial flap was advanced as an underlay to the contralateral
(left) posterior rectus sheath and secured with through-and-through #1 Maxon
sutures. These were temporarily secured with rubber-shod clamps. The
inferior 3rd of the abdominal wall was able to be closed with near-far-far-
near #1 Maxon and segmental, running #1 Maxon. The superior half to two-
thirds was unable to be closed fascia to fascia and was buttressed with this
posterior sheath/cicatricial flap.
Because this tissue appeared tenuous, it was decided to put a reinforcement of
biologic bioprosthetic mesh (Strattice). It was cut to the exact size and
shape of the defect, laid above this posterior rectus sheath and fascial flap,
and secured with the tacking sutures of #1 Maxon. A #19 Blake drain was
placed over this bioprosthetic. The anterior rectus sheath was then attempted
to be approximated. This was too tight to primarily close.
Therefore, component separation was performed on either side with incisions in
the right and left linea semilunaris to allow for medial advancement of the
anterior rectus sheath. This was then approximated on the right and left
sides with #1 Maxon near-far-far-near interrupted sutures and segmental,
running #1 Maxon. The quality of this fascia was poor, with numerous small
holes and/or areas of weakness. Therefore, another layer of bioprosthetic was
placed above this incision and secured in place with circumferential, running
2-0 Vicryl.
Prior to this closure, it was noted that the old stoma site on the right side
had a fascial defect. It was feared that if we closed his recurrent ventral
hernia, that this would bulge. Therefore, the sac was incised and this area
was closed in layers with the inside layer closed from intra-abdominal with a
near-far-far-near #1 Maxon and running #1 Maxon. The external sheath was
closed with a running #1 Maxon.
Therefore, in summary, we had a large, recurrent ventral hernia that was
closed with a posterior rectus sheath/cicatricial flap, reinforced with
bioprosthetic and bilateral component separation, and the anterior sheath
reinforced with a separate piece of bioprosthetic, and repair of a stomal
hernia, primarily.
The Scarpa's layer was closed with 2-0 Vicryl. A closed suction drain was
placed between this and the 2nd layer of bioprosthetic. The skin was closed
with 3-0 Vicryl and V-Loc, as well as Prineo. Throughout the case, bladder
pressures were monitored and were all in the safe level. Prior to the skin
closure, Marcaine was injected in the layer between the transversalis and
internal oblique, in an attempt to minimize postoperative pain.
The patient was extubated and transported to the surgical ICU in satisfactory
condition.
Can anyone tell me if creating a posterior rectus advancement flap is considered part of the component separation procedure? The report below was coded as 15734, 15734-59, 15734-59, 49565, 49568, 49560, 49568.
Humana has denied 15734 saying the procedure is not supported by the operative report. I believe 15734 was coded once to report the posterior rectus advancement flap, and then twice with mod -59 to report the left and right component separation.
OPERATIVE PROCEDURE:
The patient was placed on the operating table and after a successful induction
of anesthesia, the operative field was prepped and draped in the usual manner.
The scar was marked, as were the palpable edges of the hernia.
Incision was made on either edge of the scar and carried down through
subcutaneous tissue. The subcutaneous tissue was lifted off scar and fat
until the right left fascia was able to be identified, and this was identified
circumferentially. The scar itself was de-epithelialized. A right posterior
rectus sheath/cicatricial flap was developed, approximately 6 cm in width.
This was then advanced medially.
All adhesions were lysed to the abdominal wall. The posterior
sheath/cicatricial flap was advanced as an underlay to the contralateral
(left) posterior rectus sheath and secured with through-and-through #1 Maxon
sutures. These were temporarily secured with rubber-shod clamps. The
inferior 3rd of the abdominal wall was able to be closed with near-far-far-
near #1 Maxon and segmental, running #1 Maxon. The superior half to two-
thirds was unable to be closed fascia to fascia and was buttressed with this
posterior sheath/cicatricial flap.
Because this tissue appeared tenuous, it was decided to put a reinforcement of
biologic bioprosthetic mesh (Strattice). It was cut to the exact size and
shape of the defect, laid above this posterior rectus sheath and fascial flap,
and secured with the tacking sutures of #1 Maxon. A #19 Blake drain was
placed over this bioprosthetic. The anterior rectus sheath was then attempted
to be approximated. This was too tight to primarily close.
Therefore, component separation was performed on either side with incisions in
the right and left linea semilunaris to allow for medial advancement of the
anterior rectus sheath. This was then approximated on the right and left
sides with #1 Maxon near-far-far-near interrupted sutures and segmental,
running #1 Maxon. The quality of this fascia was poor, with numerous small
holes and/or areas of weakness. Therefore, another layer of bioprosthetic was
placed above this incision and secured in place with circumferential, running
2-0 Vicryl.
Prior to this closure, it was noted that the old stoma site on the right side
had a fascial defect. It was feared that if we closed his recurrent ventral
hernia, that this would bulge. Therefore, the sac was incised and this area
was closed in layers with the inside layer closed from intra-abdominal with a
near-far-far-near #1 Maxon and running #1 Maxon. The external sheath was
closed with a running #1 Maxon.
Therefore, in summary, we had a large, recurrent ventral hernia that was
closed with a posterior rectus sheath/cicatricial flap, reinforced with
bioprosthetic and bilateral component separation, and the anterior sheath
reinforced with a separate piece of bioprosthetic, and repair of a stomal
hernia, primarily.
The Scarpa's layer was closed with 2-0 Vicryl. A closed suction drain was
placed between this and the 2nd layer of bioprosthetic. The skin was closed
with 3-0 Vicryl and V-Loc, as well as Prineo. Throughout the case, bladder
pressures were monitored and were all in the safe level. Prior to the skin
closure, Marcaine was injected in the layer between the transversalis and
internal oblique, in an attempt to minimize postoperative pain.
The patient was extubated and transported to the surgical ICU in satisfactory
condition.